Healthcare Provider Details

I. General information

NPI: 1497005029
Provider Name (Legal Business Name): ANANDA LYRA FIDANI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23622 CALABASAS RD SUITE 339
CALABASAS CA
91302-1549
US

IV. Provider business mailing address

23622 CALABASAS ROAD SUITE 339
CALABASAS CA
91302-1594
US

V. Phone/Fax

Practice location:
  • Phone: 818-225-0117
  • Fax: 818-225-0127
Mailing address:
  • Phone: 818-225-0117
  • Fax: 818-225-0127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA22526
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: