Healthcare Provider Details

I. General information

NPI: 1730514761
Provider Name (Legal Business Name): LYDIA MAE HERNANDEZ PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYDIA MAE KANTOR PTA

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 SKYLINE BLVD APT G4
PACIFICA CA
94044
US

IV. Provider business mailing address

2400 SKYLINE BLVD APT G4
PACIFICA CA
94044
US

V. Phone/Fax

Practice location:
  • Phone: 415-336-4618
  • Fax:
Mailing address:
  • Phone: 415-336-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT6500
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: