Provider Demographics
NPI:1235409566
Name:FUENTES, ALFRED JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ALFRED
Middle Name:
Last Name:FUENTES
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14127 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-2205
Mailing Address - Country:US
Mailing Address - Phone:310-532-1650
Mailing Address - Fax:310-532-2036
Practice Address - Street 1:14127 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-2205
Practice Address - Country:US
Practice Address - Phone:310-532-1650
Practice Address - Fax:310-532-2036
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 11705363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical