Provider Demographics
NPI:1255376265
Name:FORTANASCE, MICHAEL G (DPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:FORTANASCE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:920 LOHMAN LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2906
Mailing Address - Country:US
Mailing Address - Phone:323-999-7770
Mailing Address - Fax:323-999-7796
Practice Address - Street 1:925 W FOOTHILL BLVD STE B
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-6603
Practice Address - Country:US
Practice Address - Phone:323-999-7770
Practice Address - Fax:323-999-7796
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT9651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist