Healthcare Provider Details

I. General information

NPI: 1790801512
Provider Name (Legal Business Name): PEDIATRIC & ADULT ALLERGY ASTHMA & IMMUNOLOGY SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 LAKE AVE SUITE 27
FORT WAYNE IN
46805-5428
US

IV. Provider business mailing address

3030 LAKE AVE SUITE 27
FORT WAYNE IN
46805-5428
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-5569
  • Fax: 260-422-6086
Mailing address:
  • Phone: 260-422-5569
  • Fax: 260-422-6086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: MONICA S NELSON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 260-422-5569