Provider Demographics
NPI:1861010811
Name:DESAI, MEDHA PATEL
Entity Type:Individual
Prefix:
First Name:MEDHA
Middle Name:PATEL
Last Name:DESAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 GEORGETOWN DR
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2348
Mailing Address - Country:US
Mailing Address - Phone:860-995-8292
Mailing Address - Fax:
Practice Address - Street 1:85 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2601
Practice Address - Country:US
Practice Address - Phone:860-995-8292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT145723163W00000X
CT9868363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse