MEDICARE: LUIS HERNANDEZ LSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	SA00334	TX

General Provider Information

NPI Number	:	1184800898
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUIS HERNANDEZ LSA

Provider Business Mailing Address
First Line	:	21175 TOMBALL PKWY PMB # 122
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-1655
Country	:	US
Telephone Number	:	281-256-5702
Fax Number	:

Provider Business Practice Location Address
First Line	:	21175 TOMBALL PARKWAY PMB # 122
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-1655
Country	:	US
Telephone Number	:	281-256-5702
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	01/25/2013

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