Provider Demographics
NPI:1780170092
Name:PATEL, SUPAL (APN, FNP-BC)
Entity type:Individual
Prefix:MR
First Name:SUPAL
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:APN, FNP-BC
Other - Prefix:MR
Other - First Name:SUPALKUMAR
Other - Middle Name:
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2177 OAK TREE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1082
Mailing Address - Country:US
Mailing Address - Phone:908-769-4735
Mailing Address - Fax:
Practice Address - Street 1:2177 OAK TREE RD STE 204
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1082
Practice Address - Country:US
Practice Address - Phone:908-769-4735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR16668400163WM0705X
NJ26NJ00964200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical