Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | OS12773 | FL |
NPI | 1093121089 |
---|---|
Provider Name | Ms. Carmen Maria Fernandez |
First Address | North Fort Myers, FL 33903-7099 |
Second Address | Fort Myers, FL 33905-2025 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2014 |
Last Update Date | 15/01/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
014864100 | (05) | FL |
FGU25 | FLORIDA BLUE (01) |