Healthcare Provider Details

I. General information

NPI: 1295307551
Provider Name (Legal Business Name): PRASANNAKUMAR KANUBHAI GAJERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9929 REA RD STE 101
WAXHAW NC
28173-6439
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-1055
  • Fax:
Mailing address:
  • Phone: 336-277-5314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT222842
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2025-03511
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: