Provider Demographics
NPI:1629006879
Name:DESAI, SAMIR SANMUKH (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:SANMUKH
Last Name:DESAI
Suffix:
Gender:M
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 1:1901 LONG PRAIRIE RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-4246
Mailing Address - Country:US
Mailing Address - Phone:940-736-6810
Mailing Address - Fax:
Practice Address - Street 1:1901 LONG PRAIRIE RD STE 220-80
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4246
Practice Address - Country:US
Practice Address - Phone:940-736-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04166363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L22891OtherMEDICARE PTAN #
TXPA04166OtherLICENSE NUMBER