Healthcare Provider Details

I. General information

NPI: 1174486336
Provider Name (Legal Business Name): JUNIOR FERNANDEZ FERNANDEZ SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 HIGH AVE
NYACK NY
10960-2407
US

IV. Provider business mailing address

278 HIGH AVE
NYACK NY
10960-2407
US

V. Phone/Fax

Practice location:
  • Phone: 347-613-8010
  • Fax: 347-613-8010
Mailing address:
  • Phone: 347-613-8010
  • Fax: 347-613-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number518637228
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: