Provider Demographics
NPI:1720430622
Name:PATEL, POONAM C (PA-C)
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:C
Last Name:PATEL
Suffix:
Gender:
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 1:90 MATAWAN RD STE 302
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2653
Mailing Address - Country:US
Mailing Address - Phone:732-441-7177
Mailing Address - Fax:732-441-7165
Practice Address - Street 1:123 FRANKLIN CORNER RD STE 114
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2526
Practice Address - Country:US
Practice Address - Phone:609-512-1690
Practice Address - Fax:609-512-1674
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058211363AM0700X
NJ25MP00450200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA97Medicaid