Provider Demographics
NPI:1427370469
Name:FIDELIA, MARTIN ANTONY (PA)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:ANTONY
Last Name:FIDELIA
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1421 MALABAR RD NE
Mailing Address - Street 2:PHYSICIANS OFFICE BLDG #200
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2576
Mailing Address - Country:US
Mailing Address - Phone:321-308-2660
Mailing Address - Fax:321-984-9303
Practice Address - Street 1:1421 MALABAR RD NE
Practice Address - Street 2:PHYSICIANS OFFICE BLDG #200
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2576
Practice Address - Country:US
Practice Address - Phone:321-308-2660
Practice Address - Fax:321-984-9303
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2012-07-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9105354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9105354OtherMEDICAL LICENSE NUMBER
FLPA9105354OtherMEDICAL LICENSE NUMBER