Healthcare Provider Details

I. General information

NPI: 1255908265
Provider Name (Legal Business Name): POOJA PATEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 07/11/2021
Certification Date: 07/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SANTA ROSA ST UNIT 201
SAN LUIS OBISPO CA
93405-5826
US

IV. Provider business mailing address

10 SANTA ROSA ST
SAN LUIS OBISPO CA
93405-5826
US

V. Phone/Fax

Practice location:
  • Phone: 805-544-7246
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number59398
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: