Healthcare Provider Details

I. General information

NPI: 1730577859
Provider Name (Legal Business Name): JOSUE RODRIGUEZ-HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2014
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22593 THREE NOTCH RD
CALIFORNIA MD
20619-3202
US

IV. Provider business mailing address

4989 NORTH 3RD STREET
LARAMIE WY
82072-9548
US

V. Phone/Fax

Practice location:
  • Phone: 301-862-2505
  • Fax: 301-862-2548
Mailing address:
  • Phone: 307-745-8997
  • Fax: 307-742-6146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA03072
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: