Provider Demographics
NPI:1770033714
Name:SHARMA, PRADHAN
Entity type:Individual
Prefix:MR
First Name:PRADHAN
Middle Name:
Last Name:SHARMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ELWELL AVE
Mailing Address - Street 2:
Mailing Address - City:BUDD LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07828-2803
Mailing Address - Country:US
Mailing Address - Phone:973-886-4523
Mailing Address - Fax:
Practice Address - Street 1:2901 JOLLY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2324
Practice Address - Country:US
Practice Address - Phone:610-272-8221
Practice Address - Fax:610-272-5655
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004545363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103529559Medicaid