Provider Demographics
NPI:1215481148
Name:FERNANDEZ, GREG (DPT)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N69W5289 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2156
Mailing Address - Country:US
Mailing Address - Phone:262-546-4696
Mailing Address - Fax:
Practice Address - Street 1:2225 WISCONSIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-2608
Practice Address - Country:US
Practice Address - Phone:262-474-0063
Practice Address - Fax:262-222-6281
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11288225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215481148Medicaid