Provider Demographics
NPI:1366040610
Name:FERNANDEZ, LEROY
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:FERNANDEZ
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:PO BOX 94508
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-4508
Mailing Address - Country:US
Mailing Address - Phone:505-384-7352
Mailing Address - Fax:
Practice Address - Street 1:411 S 3RD ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-4005
Practice Address - Country:US
Practice Address - Phone:575-733-0003
Practice Address - Fax:575-733-0004
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker