Basic Information
| Provider Information | |||||||||
| NPI: | 1992066864 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1124 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670025500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163004000 | ||||||||
| FaxNumber: | 3163004040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1124 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670025500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3163004000 | ||||||||
| FaxNumber: | 3163004040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2012 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 9407852 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04-38332 | 01 | KS | STATE LICENSE | OTHER |