Basic Information
| Provider Information | |||||||||
| NPI: | 1588940381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDES | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | EDWARD | ||||||||
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| OtherLastName: | FERNANDES | ||||||||
| OtherFirstName: | JIM | ||||||||
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| OtherCredential: | DPT, ATC, CSCS | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7735 ACC BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276178631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049625240 | ||||||||
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| Practice Location | |||||||||
| Address1: | FINCH YEAGER BUILDING | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277100001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196811656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 10/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251S0007X | 12483 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
No ID Information.