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NPI Code Detail

MEDICARE: KELLY FIDER PA-C

MEDICARE: KELLY FIDER PA-C
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
1363A00000XPhysician Assistant9594MN

General Provider Information

NPI Number : 1598768434
Entity Type Code : Individual
Provider Name (Legal Business Name) : KELLY FIDER PA-C
Provider Business Mailing Address
First Line : 6465 WAYZATA BLVD
Second Line : SUITE 315
City : ST LOUIS PARK
State : MN
Zip : 55426-1728
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 8100 NORTHLAND DR
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55431-4800
Country : US
Telephone Number : 952-831-8742
Fax Number : 952-831-1626
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/24/2005
Last Update Date : 07/08/2007

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Directions to “ KELLY FIDER PA-C” Practice Location

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