Provider Demographics
NPI:1316392921
Name:FERNANDEZ, SERGIO (PTA 26177)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:PTA 26177
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 SW 149TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-1436
Mailing Address - Country:US
Mailing Address - Phone:305-302-2506
Mailing Address - Fax:786-360-5258
Practice Address - Street 1:12150 SW 128TH CT
Practice Address - Street 2:SUITE # 129
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4647
Practice Address - Country:US
Practice Address - Phone:786-732-2593
Practice Address - Fax:305-381-2523
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA26177225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant