Provider Demographics
NPI:1083437750
Name:ADDAE, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ADDAE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29252 SOUTHERNESS
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-4399
Mailing Address - Country:US
Mailing Address - Phone:609-742-3405
Mailing Address - Fax:
Practice Address - Street 1:29252 SOUTHERNESS
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4399
Practice Address - Country:US
Practice Address - Phone:609-742-3405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant