Healthcare Provider Details

I. General information

NPI: 1326798851
Provider Name (Legal Business Name): JASON HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2022
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CLUB DR
VALLEJO CA
94592-1187
US

IV. Provider business mailing address

9446 MISTY RIVER WAY
ELK GROVE CA
95624-1264
US

V. Phone/Fax

Practice location:
  • Phone: 707-638-5809
  • Fax:
Mailing address:
  • Phone: 916-230-5141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65141
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: