Provider Demographics
NPI:1114627650
Name:PATEL, KUSH GHANSHYAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:KUSH
Middle Name:GHANSHYAM
Last Name:PATEL
Suffix:
Gender:M
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 1:233 BROAD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-3549
Mailing Address - Country:US
Mailing Address - Phone:203-810-4151
Mailing Address - Fax:203-783-9689
Practice Address - Street 1:233 BROAD ST STE 1
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3549
Practice Address - Country:US
Practice Address - Phone:475-355-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-03
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT6471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program