Healthcare Provider Details

I. General information

NPI: 1033603832
Provider Name (Legal Business Name): DEEP GAUTAM PATEL PA-C, ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11685 ALPHARETTA HWY
ROSWELL GA
30076-4913
US

IV. Provider business mailing address

5575 FORDS CROSSING CT NW
ACWORTH GA
30101-4806
US

V. Phone/Fax

Practice location:
  • Phone: 770-619-3842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: