Provider Demographics
NPI:1003588534
Name:FERNANDEZ, GILBERT (PTA)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 FLORES LN
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-1905
Mailing Address - Country:US
Mailing Address - Phone:760-889-6006
Mailing Address - Fax:760-295-4455
Practice Address - Street 1:119 FLORES LN
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-1905
Practice Address - Country:US
Practice Address - Phone:760-889-6006
Practice Address - Fax:760-295-4455
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8677225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant