Healthcare Provider Details

I. General information

NPI: 1043146384
Provider Name (Legal Business Name): EDNA M HERNANDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MAY AVE
PAGE ND
58064-4004
US

IV. Provider business mailing address

112 MAY AVE
PAGE ND
58064-4004
US

V. Phone/Fax

Practice location:
  • Phone: 701-741-6851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1452293
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: