Provider Demographics
NPI:1700323409
Name:FERNANDEZ, CARLO
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:
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 1:385 S MANCHESTER AVE
Mailing Address - Street 2:UNIT 4025
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17752 SKY PARK CIR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6419
Practice Address - Country:US
Practice Address - Phone:949-885-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48205225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant