Provider Demographics
NPI:1669725842
Name:THAKKAR, DISHANK (PA-C)
Entity type:Individual
Prefix:
First Name:DISHANK
Middle Name:
Last Name:THAKKAR
Suffix:
Gender:M
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 1:325 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-1617
Mailing Address - Country:US
Mailing Address - Phone:609-924-8131
Mailing Address - Fax:609-924-8532
Practice Address - Street 1:325 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1617
Practice Address - Country:US
Practice Address - Phone:609-924-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016160363A00000X
NJ25MP00315200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant