Provider Demographics
NPI:1780205914
Name:FUNDANO, ARIEL LATONIO
Entity Type:Individual
Prefix:MR
First Name:ARIEL
Middle Name:LATONIO
Last Name:FUNDANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4706 EMDEN HOLW
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5837
Mailing Address - Country:US
Mailing Address - Phone:708-898-8378
Mailing Address - Fax:
Practice Address - Street 1:7710 W INTERSTATE 10
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4711
Practice Address - Country:US
Practice Address - Phone:210-377-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2119667225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant