Healthcare Provider Details

I. General information

NPI: 1831753912
Provider Name (Legal Business Name): ALEX FIDLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VAN NESS AVE
SAN FRANCISCO CA
94109-6919
US

IV. Provider business mailing address

3611 UNIVERSITY DR APT 19J
DURHAM NC
27707-6218
US

V. Phone/Fax

Practice location:
  • Phone: 415-600-1010
  • Fax:
Mailing address:
  • Phone: 805-455-4191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56046
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: