Healthcare Provider Details

I. General information

NPI: 1770180135
Provider Name (Legal Business Name): SHAMA PATEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 BOUND BROOK RD STE A
DUNELLEN NJ
08812-1079
US

IV. Provider business mailing address

760 BOUND BROOK RD STE A
DUNELLEN NJ
08812-1079
US

V. Phone/Fax

Practice location:
  • Phone: 732-968-2811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00574900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: