Healthcare Provider Details

I. General information

NPI: 1417845942
Provider Name (Legal Business Name): MARCO ANTONIO CUEVAS HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 MADRONE WAY
SAN PABLO CA
94806-2174
US

IV. Provider business mailing address

1321 MADRONE WAY
SAN PABLO CA
94806-2174
US

V. Phone/Fax

Practice location:
  • Phone: 510-941-6987
  • Fax:
Mailing address:
  • Phone: 510-941-6987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: