Provider Demographics
NPI:1265467484
Name:FERNANDEZ, MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 33RD ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2329
Mailing Address - Country:US
Mailing Address - Phone:718-707-6970
Mailing Address - Fax:718-707-6977
Practice Address - Street 1:3270 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-2643
Practice Address - Country:US
Practice Address - Phone:718-626-2699
Practice Address - Fax:718-626-0923
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023920-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0632ACMedicare PIN