MEDICARE: CENNIA NICOLE HERNANDEZ PA-C

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	363A00000X	Physician Assistant	9656	AZ

General Provider Information

NPI Number	:	1306275037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CENNIA NICOLE HERNANDEZ PA-C

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	1775 W SAINT MARYS RD STE 116
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85745-2662
Country	:	US
Telephone Number	:	520-293-5757
Fax Number	:	520-293-7358

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	02/24/2026

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