MEDICARE: MR. EDGAR FIRME FORTIN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	95028352	CA

General Provider Information

NPI Number	:	1174339972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDGAR FIRME FORTIN NP

Provider Business Mailing Address
First Line	:	3498 LINDA VISTA RD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1440
Country	:	US
Telephone Number	:	323-717-2139
Fax Number	:

Provider Business Practice Location Address
First Line	:	3498 LINDA VISTA RD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91206-1440
Country	:	US
Telephone Number	:	323-717-2139
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2024
Last Update Date	:	12/06/2024

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