Healthcare Provider Details

I. General information

NPI: 1144424144
Provider Name (Legal Business Name): RICHARD LEE FIDLER II CRNA, CRNP, MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST BLDG 6 DEPT OF ANESTHESIOLOGY, ROOM 201
SAN FRANCISCO CA
94121-1545
US

IV. Provider business mailing address

182 STANYAN ST APT #1
SAN FRANCISCO CA
94118-4268
US

V. Phone/Fax

Practice location:
  • Phone: 415-221-4810
  • Fax:
Mailing address:
  • Phone: 804-306-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number17255
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: