Basic Information
Provider Information
NPI: 1003005109
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FETTMAN
FirstName: NICHOLAS
MiddleName: AARON
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2876 SYCAMORE DR
Address2: SUITE 303
City: SIMI VALLEY
State: CA
PostalCode: 930651530
CountryCode: US
TelephoneNumber: 8055277320
FaxNumber: 8055272426
Practice Location
Address1: 1700 N ROSE AVE
Address2: SUITE 460
City: OXNARD
State: CA
PostalCode: 930303790
CountryCode: US
TelephoneNumber: 8059830395
FaxNumber: 8059830463
Other Information
ProviderEnumerationDate: 10/15/2007
LastUpdateDate: 06/19/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Y00000XA116624CAY Allopathic & Osteopathic PhysiciansOtolaryngology 
207Y00000X2006018899MON Allopathic & Osteopathic PhysiciansOtolaryngology 

No ID Information.


Home