Healthcare Provider Details

I. General information

NPI: 1730467143
Provider Name (Legal Business Name): PRIYA P PATEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 WILSON TER STE 240
GLENDALE CA
91206-4033
US

IV. Provider business mailing address

1112 MONTANA AVE STE 912
SANTA MONICA CA
90403-1652
US

V. Phone/Fax

Practice location:
  • Phone: 310-205-3555
  • Fax: 310-205-3553
Mailing address:
  • Phone: 310-205-3555
  • Fax: 310-205-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA9105796
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA55343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: