Provider Demographics
NPI:1205447224
Name:PATEL, AMITA VIPUL
Entity type:Individual
Prefix:
First Name:AMITA
Middle Name:VIPUL
Last Name:PATEL
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 1:6144 ROUTE 25A
Mailing Address - Street 2:STE 13
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2008
Mailing Address - Country:US
Mailing Address - Phone:516-433-8106
Mailing Address - Fax:
Practice Address - Street 1:6144 ROUTE 25A STE 13
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2008
Practice Address - Country:US
Practice Address - Phone:516-495-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF343482-1363L00000X
NYF343482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner