Provider Demographics
NPI:1730467143
Name:PATEL, PRIYA P (PA-C)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:P
Last Name:PATEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1112 MONTANA AVE STE 912
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1652
Mailing Address - Country:US
Mailing Address - Phone:310-205-3555
Mailing Address - Fax:310-205-3553
Practice Address - Street 1:1505 WILSON TER STE 240
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4033
Practice Address - Country:US
Practice Address - Phone:310-205-3555
Practice Address - Fax:310-205-3553
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9105796208000000X
CAPA55343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004345000Medicaid