Healthcare Provider Details

I. General information

NPI: 1558916478
Provider Name (Legal Business Name): RICKY PATEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 N POINT PKWY STE 207
ALPHARETTA GA
30005-4381
US

IV. Provider business mailing address

4552 OLD DIXIE HWY APT 327
FOREST PARK GA
30297-1766
US

V. Phone/Fax

Practice location:
  • Phone: 770-559-8725
  • Fax:
Mailing address:
  • Phone: 813-810-6710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5019
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: