Provider Demographics
NPI:1588091243
Name:BHANGU, THARA (PA-C)
Entity type:Individual
Prefix:
First Name:THARA
Middle Name:
Last Name:BHANGU
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 1:7793 SW 102ND LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2690
Mailing Address - Country:US
Mailing Address - Phone:305-775-2435
Mailing Address - Fax:
Practice Address - Street 1:7600 SW 87TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3635
Practice Address - Country:US
Practice Address - Phone:305-275-5525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107421363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical