Provider Demographics
NPI:1083468169
Name:FERNANDEZ DE LA VEGA, JOAN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:FERNANDEZ DE LA VEGA
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 1:8215 SW 72ND AVE APT 809
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-7789
Mailing Address - Country:US
Mailing Address - Phone:786-236-6748
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 191227
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00919-1227
Practice Address - Country:US
Practice Address - Phone:787-758-2000
Practice Address - Fax:787-771-7699
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16922-I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program