Healthcare Provider Details

I. General information

NPI: 1518791011
Provider Name (Legal Business Name): MARIO ANDREW HERNANDEZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4343 N 16TH ST
PHOENIX AZ
85016-5338
US

IV. Provider business mailing address

2769 S BIRCH ST
GILBERT AZ
85295-2050
US

V. Phone/Fax

Practice location:
  • Phone: 602-274-4343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN169149
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: