Healthcare Provider Details

I. General information

NPI: 1093367344
Provider Name (Legal Business Name): BERNARDO FERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2641 E STRINGHAM AVE APT 303C
SLC UT
84109-3984
US

IV. Provider business mailing address

2641 E STRINGHAM AVE APT 303C
SLC UT
84109-3984
US

V. Phone/Fax

Practice location:
  • Phone: 559-906-2823
  • Fax:
Mailing address:
  • Phone: 559-906-2823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11952470-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: