Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | AT8677 | CA |
NPI | 1003588534 |
---|---|
Provider Name | Gilbert Fernandez |
First Address | Vista, CA 92083-1905 |
Second Address | Vista, CA 92083-1905 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/10/2021 |
Last Update Date | 04/10/2021 |