Provider Demographics
NPI:1174486336
Name:FERNANDEZ, JUNIOR FERNANDEZ SR
Entity type:Individual
Prefix:
First Name:JUNIOR
Middle Name:FERNANDEZ
Last Name:FERNANDEZ
Suffix:SR
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 1:278 HIGH AVE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-2407
Mailing Address - Country:US
Mailing Address - Phone:347-613-8010
Mailing Address - Fax:347-613-8010
Practice Address - Street 1:278 HIGH AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-2407
Practice Address - Country:US
Practice Address - Phone:347-613-8010
Practice Address - Fax:347-613-8010
Is Sole Proprietor?:Yes
Enumeration Date:2025-12-04
Last Update Date:2025-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY518637228172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver