Provider Demographics
NPI:1770854531
Name:FORTUNAT, CLIFF R (PTA)
Entity Type:Individual
Prefix:
First Name:CLIFF
Middle Name:R
Last Name:FORTUNAT
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 1:1350 W VAN BUREN ST APT 2018
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-2584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE STE 8
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5665
Practice Address - Country:US
Practice Address - Phone:623-466-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9477APTA225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant