Provider Demographics
NPI:1467040998
Name:BARDALES-DELGADO, FATIMA ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:
First Name:FATIMA
Middle Name:ALEXANDRA
Last Name:BARDALES-DELGADO
Suffix:
Gender:F
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 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:100 BOWMAN DR LOWR LEVEL1
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9612
Practice Address - Country:US
Practice Address - Phone:856-247-3000
Practice Address - Fax:856-247-2597
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MP00649500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program