Provider Demographics
NPI:1164099784
Name:FERNANDEZ, LUISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LUISA
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 WAUGHTOWN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-2236
Mailing Address - Country:US
Mailing Address - Phone:336-792-1515
Mailing Address - Fax:336-792-1518
Practice Address - Street 1:512 WAUGHTOWN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-2236
Practice Address - Country:US
Practice Address - Phone:336-792-1515
Practice Address - Fax:336-792-1518
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant