Provider Demographics
NPI:1932631645
Name:PATEL, SHIVANI MAHESH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SHIVANI
Middle Name:MAHESH
Last Name:PATEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHIVANIBEN
Other - Middle Name:MAHESH
Other - Last Name:PATEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10058 BAYMEADOWS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7177
Mailing Address - Country:US
Mailing Address - Phone:904-636-5400
Mailing Address - Fax:904-928-0654
Practice Address - Street 1:10058 BAYMEADOWS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7177
Practice Address - Country:US
Practice Address - Phone:904-636-5400
Practice Address - Fax:904-928-0654
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110263363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018008600Medicaid
FL024771000Medicaid