Healthcare Provider Details

I. General information

NPI: 1578547782
Provider Name (Legal Business Name): FIDEL ANDRADE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11420 WARNER AVE
FOUNTAIN VALLEY CA
92708-2529
US

IV. Provider business mailing address

17360 BROOKHURST STREET ATTN: CREDENTIALING DEPARTMENT
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 714-549-1300
  • Fax: 714-433-3100
Mailing address:
  • Phone: 657-241-3592
  • Fax: 714-665-4614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 13293
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: