Provider Demographics
NPI:1477750396
Name:FERNANDEZ, MANICAR DOMANTAY (PT)
Entity Type:Individual
Prefix:
First Name:MANICAR
Middle Name:DOMANTAY
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:610-991-2034
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:530 TANGLEWOOD LN
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2627
Practice Address - Country:US
Practice Address - Phone:610-991-2034
Practice Address - Fax:610-438-2046
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006025A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN229240Medicare ID - Type UnspecifiedPART B GROUP CARRIER NUMB
IN229240CMedicare ID - Type UnspecifiedPART B INDIVIDUAL CARRIER