Provider Demographics
NPI:1417404237
Name:PATEL, SHRUTI (PA-C)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:PIERSON
Mailing Address - State:FL
Mailing Address - Zip Code:32180-3024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 W PLYMOUTH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3215
Practice Address - Country:US
Practice Address - Phone:386-736-7933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109687363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical