Healthcare Provider Details

I. General information

NPI: 1780170092
Provider Name (Legal Business Name): SUPAL PATEL APN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. SUPALKUMAR PATEL

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2177 OAK TREE RD STE 204
EDISON NJ
08820-1082
US

IV. Provider business mailing address

2177 OAK TREE RD STE 204
EDISON NJ
08820-1082
US

V. Phone/Fax

Practice location:
  • Phone: 908-769-4735
  • Fax:
Mailing address:
  • Phone: 908-769-4735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number26NR16668400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00964200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: