Provider Demographics
NPI:1508230137
Name:FUENTES, MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FUENTES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 S 1ST ST
Mailing Address - Street 2:APT 328
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-6686
Mailing Address - Country:US
Mailing Address - Phone:210-601-2349
Mailing Address - Fax:
Practice Address - Street 1:117-B LOUIS HENNA BLVD
Practice Address - Street 2:STE. 200
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664
Practice Address - Country:US
Practice Address - Phone:512-255-9634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1268326172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker