Provider Demographics
NPI:1659187300
Name:PATEL, MITTAL
Entity type:Individual
Prefix:
First Name:MITTAL
Middle Name:
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 1:12228 PAXTON GLEN TER
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-7166
Mailing Address - Country:US
Mailing Address - Phone:805-504-6783
Mailing Address - Fax:
Practice Address - Street 1:12228 PAXTON GLEN TER
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-7166
Practice Address - Country:US
Practice Address - Phone:805-504-6783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001275667163WC0200X
VA0024187380363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine