Healthcare Provider Details

I. General information

NPI: 1528669942
Provider Name (Legal Business Name): LORENZO ANTONIO FERNANDEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 N SEMORAN BLVD
WINTER PARK FL
32792-2840
US

IV. Provider business mailing address

1780 WELHAM ST APT 437
ORLANDO FL
32814-6855
US

V. Phone/Fax

Practice location:
  • Phone: 407-679-1515
  • Fax:
Mailing address:
  • Phone: 786-474-5650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA30424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: