Provider Demographics
NPI:1538486436
Name:FERNANDEZ, JOSHUA TYLER JESUS (LMP)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:TYLER JESUS
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 NW BYRON ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3212 NW BYRON ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9154
Practice Address - Country:US
Practice Address - Phone:360-692-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-01
Last Update Date:2010-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60152368225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist