Provider Demographics
NPI:1275034837
Name:GAUTAM-DHAKAL, MUKTA
Entity Type:Individual
Prefix:
First Name:MUKTA
Middle Name:
Last Name:GAUTAM-DHAKAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 WILLIAMSON ST APT C5
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3663
Mailing Address - Country:US
Mailing Address - Phone:201-315-5855
Mailing Address - Fax:
Practice Address - Street 1:12359 SUNRISE VALLEY DR STE 320
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3463
Practice Address - Country:US
Practice Address - Phone:703-596-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00806800363LA2100X
VA0024177376363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care