Provider Demographics
NPI:1457740516
Name:PATEL, NISHA (PA-C)
Entity type:Individual
Prefix:
First Name:NISHA
Middle Name:
Last Name:PATEL
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 1:5388 OLD WOODALL CT
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30360-1266
Mailing Address - Country:US
Mailing Address - Phone:678-467-5595
Mailing Address - Fax:
Practice Address - Street 1:631 PROFESSIONAL DR STE 360
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3370
Practice Address - Country:US
Practice Address - Phone:678-312-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant