Provider Demographics
NPI:1518368745
Name:PATEL, MIRA (APN)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N WOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036
Mailing Address - Country:US
Mailing Address - Phone:908-587-9300
Mailing Address - Fax:908-587-1901
Practice Address - Street 1:520 N WOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-4147
Practice Address - Country:US
Practice Address - Phone:908-587-9300
Practice Address - Fax:908-587-1901
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00520000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ402986Medicare PIN