Provider Demographics
NPI:1063291508
Name:PATEL, ESHANI GAUTAM (PA)
Entity type:Individual
Prefix:
First Name:ESHANI
Middle Name:GAUTAM
Last Name:PATEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12070 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-3771
Mailing Address - Country:US
Mailing Address - Phone:562-777-7500
Mailing Address - Fax:
Practice Address - Street 1:11015 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-4601
Practice Address - Country:US
Practice Address - Phone:844-804-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64187363A00000X
101YM0800X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health