Provider Demographics
NPI:1609112077
Name:FIDEL, ANTHONY RAYMOND
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RAYMOND
Last Name:FIDEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:
Other - Last Name:LECHUGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25588 MAITLAND DR
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94542-1823
Mailing Address - Country:US
Mailing Address - Phone:510-921-2532
Mailing Address - Fax:
Practice Address - Street 1:25588 MAITLAND DR
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94542-1823
Practice Address - Country:US
Practice Address - Phone:510-921-2532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA829477163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse