Provider Demographics
NPI:1609391887
Name:FERNANDEZ, EDWARD JASTIA (PTA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JASTIA
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27125 SIERRA HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91351-5429
Mailing Address - Country:US
Mailing Address - Phone:661-250-9940
Mailing Address - Fax:661-250-9959
Practice Address - Street 1:3425 W VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-1545
Practice Address - Country:US
Practice Address - Phone:818-955-8855
Practice Address - Fax:818-955-8833
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48715225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant