MEDICARE: ANDREW LAZARO FONTICIELLA PA STUDENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA67745	CA
2	390200000X	Student in an Organized Health Care Education/Training Program		CA

General Provider Information

NPI Number	:	1023814001
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW LAZARO FONTICIELLA PA STUDENT

Provider Business Mailing Address
First Line	:	16037 VIA DEL SOL
Second Line	:
City	:	SAN LORENZO
State	:	CA
Zip	:	94580-2407
Country	:	US
Telephone Number	:	818-935-7076
Fax Number	:

Provider Business Practice Location Address
First Line	:	16037 VIA DEL SOL
Second Line	:
City	:	SAN LORENZO
State	:	CA
Zip	:	94580-2407
Country	:	US
Telephone Number	:	818-935-7076
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2025
Last Update Date	:	04/10/2026

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