Provider Demographics
NPI:1679229876
Name:FERNANDEZ, MICHAEL BRANDON (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRANDON
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21827 ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-1490
Mailing Address - Country:US
Mailing Address - Phone:909-868-8427
Mailing Address - Fax:
Practice Address - Street 1:2600 PACIFIC COAST HWY STE 150
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-2144
Practice Address - Country:US
Practice Address - Phone:949-640-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist