Provider Demographics
NPI:1932471257
Name:FERNANDEZ, TITO AUGUSTO
Entity Type:Individual
Prefix:MR
First Name:TITO
Middle Name:AUGUSTO
Last Name:FERNANDEZ
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:PO BOX 221135
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20153-1135
Mailing Address - Country:US
Mailing Address - Phone:703-349-1379
Mailing Address - Fax:
Practice Address - Street 1:12011 LEE JACKSON MEMORIAL HWY STE 501
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033
Practice Address - Country:US
Practice Address - Phone:703-349-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO96131246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant