Healthcare Provider Details

I. General information

NPI: 1295307759
Provider Name (Legal Business Name): DISHA PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 07/14/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4285 JIM MOORE RD # 200
DACULA GA
30019-1016
US

IV. Provider business mailing address

3400 OLD MILTON PKWY STE 270
ALPHARETTA GA
30005-3707
US

V. Phone/Fax

Practice location:
  • Phone: 770-442-1911
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: