Healthcare Provider Details

I. General information

NPI: 1770854531
Provider Name (Legal Business Name): CLIFF R FORTUNAT PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20325 N 51ST AVE STE 8
GLENDALE AZ
85308-5665
US

IV. Provider business mailing address

1350 W VAN BUREN ST APT 2018
PHOENIX AZ
85007-2584
US

V. Phone/Fax

Practice location:
  • Phone: 623-466-6350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9477APTA
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: