Provider Demographics
NPI:1386850998
Name:BEDOLLA, JUAN ALFREDO
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:ALFREDO
Last Name:BEDOLLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:ALFREDO
Other - Last Name:BEDOLLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 25042
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-5042
Mailing Address - Country:US
Mailing Address - Phone:559-369-4625
Mailing Address - Fax:559-693-7259
Practice Address - Street 1:1350 O ST STE 302
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1828
Practice Address - Country:US
Practice Address - Phone:559-369-4625
Practice Address - Fax:559-369-7259
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95059739163WP0808X, 363LF0000X
CA95005969363LP0808X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health