Provider Demographics
NPI:1093545451
Name:MEHTA, PRIYANKA (PA-C)
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:MEHTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 DOLPHIN LN
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-6208
Mailing Address - Country:US
Mailing Address - Phone:516-640-8776
Mailing Address - Fax:
Practice Address - Street 1:150 BROADHOLLOW RD STE 120
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4901
Practice Address - Country:US
Practice Address - Phone:651-401-8795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032100-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant