Provider Demographics
NPI:1891348165
Name:BRAHMBHATT, MIRA RAJU (PA-C)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:RAJU
Last Name:BRAHMBHATT
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 1:69 HAGGERTY DR
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1129 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-7127
Practice Address - Country:US
Practice Address - Phone:973-500-2686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00524400207R00000X
TXPATEMP363A00000X
TXPA14849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine