Provider Demographics
NPI:1902924814
Name:SIDARTA, ASTRID (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ASTRID
Middle Name:
Last Name:SIDARTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 W ALAMEDA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4800
Mailing Address - Country:US
Mailing Address - Phone:818-295-6944
Mailing Address - Fax:818-295-6953
Practice Address - Street 1:2601 W ALAMEDA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4800
Practice Address - Country:US
Practice Address - Phone:818-295-6944
Practice Address - Fax:818-295-6953
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant