Provider Demographics
NPI:1073758686
Name:FONSECA CORDOBA, MERCEDES (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:FONSECA CORDOBA
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 26TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1245
Mailing Address - Country:US
Mailing Address - Phone:612-721-2491
Mailing Address - Fax:612-728-2400
Practice Address - Street 1:2450 26TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1245
Practice Address - Country:US
Practice Address - Phone:612-721-2491
Practice Address - Fax:612-728-2400
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6011225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist