Healthcare Provider Details

I. General information

NPI: 1982141636
Provider Name (Legal Business Name): JORGE ANTONIO HERNANDEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3516 NE 12TH AVE
CAPE CORAL FL
33909-6432
US

IV. Provider business mailing address

3516 NE 12TH AVE
CAPE CORAL FL
33909-6432
US

V. Phone/Fax

Practice location:
  • Phone: 239-565-2433
  • Fax:
Mailing address:
  • Phone: 239-565-2433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 17335
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: