Provider Demographics
NPI:1699928846
Name:PATEL, PALAKKUMAR B (PA -C)
Entity type:Individual
Prefix:
First Name:PALAKKUMAR
Middle Name:B
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 1:1148 GRUNDY AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2633
Mailing Address - Country:US
Mailing Address - Phone:631-219-3557
Mailing Address - Fax:
Practice Address - Street 1:60 N COUNTRY RD STE 203
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2188
Practice Address - Country:US
Practice Address - Phone:631-928-3444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-01
Last Update Date:2008-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant