Provider Demographics
NPI:1356697577
Name:FERNANDEZ, BENJAMIN COREY (C-AA, DPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:COREY
Last Name:FERNANDEZ
Suffix:
Gender:M
Credentials:C-AA, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2909
Mailing Address - Country:US
Mailing Address - Phone:850-650-7606
Mailing Address - Fax:
Practice Address - Street 1:1225 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-2909
Practice Address - Country:US
Practice Address - Phone:850-650-7606
Practice Address - Fax:850-337-1698
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27491225100000X
FLAA472367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0CP4OtherBCBS
P01240342OtherRAILROAD MEDICARE
FL101045800Medicaid