Provider Demographics
NPI:1578547782
Name:ANDRADE, FIDEL (PA)
Entity Type:Individual
Prefix:MR
First Name:FIDEL
Middle Name:
Last Name:ANDRADE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17360 BROOKHURST STREET
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-3720
Mailing Address - Country:US
Mailing Address - Phone:657-241-3592
Mailing Address - Fax:714-665-4614
Practice Address - Street 1:11420 WARNER AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-2529
Practice Address - Country:US
Practice Address - Phone:714-549-1300
Practice Address - Fax:714-433-3100
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 13293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS14780Medicare UPIN
CAWPA13293AMedicare PIN
CABM212UMedicare PIN