Provider Demographics
NPI:1669981726
Name:FERNANDES, ANDRE LAGE
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:LAGE
Last Name:FERNANDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17110 CARRINGTON PARK DR APT 824
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2632
Mailing Address - Country:US
Mailing Address - Phone:407-437-6637
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-974-5699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI33186390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program