Provider Demographics
NPI:1538559190
Name:DESAI, MIRA (AGPCNP)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746715
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6715
Mailing Address - Country:US
Mailing Address - Phone:773-352-1515
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:1825 ROCKBRIDGE RD STE 15B
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3306
Practice Address - Country:US
Practice Address - Phone:470-444-3134
Practice Address - Fax:470-276-4370
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN309281363LA2200X
RIAPRN03074363LG0600X
CT13875363LG0600X
VA0001299163363LG0600X
IL277.002161363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health