Basic Information
| Provider Information | |||||||||
| NPI: | 1427370469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIDELIA | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | ANTONY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1421 MALABAR RD NE | ||||||||
| Address2: | PHYSICIANS OFFICE BLDG #200 | ||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329072576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213082660 | ||||||||
| FaxNumber: | 3219849303 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 MALABAR RD NE | ||||||||
| Address2: | PHYSICIANS OFFICE BLDG #200 | ||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329072576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213082660 | ||||||||
| FaxNumber: | 3219849303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9105354 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA9105354 | 01 | FL | MEDICAL LICENSE NUMBER | OTHER |