Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | 17802 | AZ |
NPI | 1104817378 |
---|---|
Provider Name | Barry Fernando |
First Address | Phoenix, AZ 85016-4351 |
Second Address | Phoenix, AZ 85016-4351 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2005 |
Last Update Date | 27/08/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BF1512258 | DEA (01) | |
D88957 | (02) |