Basic Information
| Provider Information | |||||||||
| NPI: | 1205389350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIEDLER | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BREZOVAR | ||||||||
| OtherFirstName: | KRISTIN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17181 WOODMERE DR | ||||||||
| Address2: | |||||||||
| City: | CHAGRIN FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440234662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628948547 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18101 LORAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441115612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164767000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2016 | ||||||||
| LastUpdateDate: | 08/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50.004742RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.