Provider Demographics
NPI:1578105664
Name:PATEL, MIRA S (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:S
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 1:6708 WINDERMERE CT
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-8611
Mailing Address - Country:US
Mailing Address - Phone:610-745-0918
Mailing Address - Fax:
Practice Address - Street 1:17TH & CHEW
Practice Address - Street 2:SUITE 101
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18105-7017
Practice Address - Country:US
Practice Address - Phone:610-969-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant