Healthcare Provider Details

I. General information

NPI: 1609391887
Provider Name (Legal Business Name): EDWARD JASTIA FERNANDEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 08/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 W VICTORY BLVD
BURBANK CA
91505-1545
US

IV. Provider business mailing address

27125 SIERRA HWY STE 203
CANYON COUNTRY CA
91351-5429
US

V. Phone/Fax

Practice location:
  • Phone: 818-955-8855
  • Fax: 818-955-8833
Mailing address:
  • Phone: 661-250-9940
  • Fax: 661-250-9959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number48715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: