Provider Demographics
NPI:1871147173
Name:FERNANDEZ, JORGE ANTONIO (SURGICAL ASSISTANT)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ANTONIO
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6131 AZTEC RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-2012
Mailing Address - Country:US
Mailing Address - Phone:915-704-6568
Mailing Address - Fax:
Practice Address - Street 1:6131 AZTEC RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-2012
Practice Address - Country:US
Practice Address - Phone:915-704-6568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19-319246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant