Healthcare Provider Details

I. General information

NPI: 1902924814
Provider Name (Legal Business Name): ASTRID SIDARTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 W ALAMEDA AVE SUITE 101
BURBANK CA
91505-4800
US

IV. Provider business mailing address

2601 W ALAMEDA AVE SUITE 101
BURBANK CA
91505-4800
US

V. Phone/Fax

Practice location:
  • Phone: 818-295-6944
  • Fax: 818-295-6953
Mailing address:
  • Phone: 818-295-6944
  • Fax: 818-295-6953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: