Provider Demographics
NPI:1013988955
Name:FUENTES, EDMAN (PAC)
Entity Type:Individual
Prefix:MR
First Name:EDMAN
Middle Name:
Last Name:FUENTES
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5725 W LAS POSITAS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-4054
Mailing Address - Country:US
Mailing Address - Phone:925-469-6274
Mailing Address - Fax:925-924-1769
Practice Address - Street 1:900 GREENLEY RD
Practice Address - Street 2:SUITE 914
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5287
Practice Address - Country:US
Practice Address - Phone:925-469-6274
Practice Address - Fax:925-924-1769
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA51630363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291613400Medicaid
CAPA51630OtherMEDICAL LICENSE
FLPA9102297OtherMEDICAL LICENSE
FLPA9102297OtherMEDICAL LICENSE
FL291613400Medicaid