Basic Information
| Provider Information | |||||||||
| NPI: | 1902924814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIDARTA | ||||||||
| FirstName: | ASTRID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 W ALAMEDA AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182956944 | ||||||||
| FaxNumber: | 8182956953 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 W ALAMEDA AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BURBANK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 915054800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182956944 | ||||||||
| FaxNumber: | 8182956953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA16137 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.