Provider Demographics
NPI:1710427661
Name:FERNANDEZ, KEVEN BRYAN (PTA)
Entity Type:Individual
Prefix:
First Name:KEVEN
Middle Name:BRYAN
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 1:8800 NW 108TH LN
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-4525
Mailing Address - Country:US
Mailing Address - Phone:305-205-0668
Mailing Address - Fax:
Practice Address - Street 1:13717 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-1106
Practice Address - Country:US
Practice Address - Phone:305-252-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-26
Last Update Date:2017-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26995225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant