Basic Information
Provider Information
NPI: 1003801598
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PATEL
FirstName: NEHA
MiddleName: D
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1245 W GRANADA BLVD
Address2:  
City: ORMOND BEACH
State: FL
PostalCode: 321745914
CountryCode: US
TelephoneNumber: 3863179055
FaxNumber:  
Practice Location
Address1: 1245 W GRANADA BLVD
Address2:  
City: ORMOND BEACH
State: FL
PostalCode: 321745914
CountryCode: US
TelephoneNumber: 3863179055
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/12/2005
LastUpdateDate: 12/12/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/12/2019

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363AM0700XPA9109904FLY Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
363AM0700X25MP00104600NJN Physician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical

ID Information
IDTypeStateIssuerDescription
709340305NJ MEDICAID


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