Provider Demographics
NPI:1679305288
Name:FERNANDEZ, ISAAC (PTA)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:FERNANDEZ
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 1:861 VIA GLORIETA
Mailing Address - Street 2:
Mailing Address - City:SUNLAND PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88063-9629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 PARAGON LN STE 218
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-6317
Practice Address - Country:US
Practice Address - Phone:915-213-1289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2155414225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty