Provider Demographics
NPI:1194725994
Name:FERNANDO, MARIA CORAZON G (MD)
Entity type:Individual
Prefix:
First Name:MARIA CORAZON
Middle Name:G
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:M CORAZON
Other - Middle Name:G
Other - Last Name:FERNANDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:231 N SHIPPEN ST
Mailing Address - Street 2:SUITE 21-B
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2770
Mailing Address - Country:US
Mailing Address - Phone:717-239-0320
Mailing Address - Fax:717-239-0321
Practice Address - Street 1:231 N SHIPPEN ST
Practice Address - Street 2:SUITE 21-B
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2770
Practice Address - Country:US
Practice Address - Phone:717-239-0320
Practice Address - Fax:717-239-0321
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2008-04-03
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-07
Provider Licenses
StateLicense IDTaxonomies
PAMD032055E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA556629XWTMedicare PIN