1790088128 NPI number — SHRADDHA N PATEL PA-C

Table of content: SHRADDHA N PATEL PA-C (NPI 1790088128)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790088128 NPI number — SHRADDHA N PATEL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATEL
Provider First Name:
SHRADDHA
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAHADEVIA
Provider Other First Name:
SHRADDHA
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790088128
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
774 CHRISTIANA RD STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19713-4221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-731-3017
Provider Business Mailing Address Fax Number:
302-292-8102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
774 CHRISTIANA RD STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-4221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-731-3017
Provider Business Practice Location Address Fax Number:
302-292-8102
Provider Enumeration Date:
12/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  C5-0000809 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0222075 . This is a "BLUE CROSS BLUE SHIELD GROUP" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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