Healthcare Provider Details

I. General information

NPI: 1083477228
Provider Name (Legal Business Name): ALICIA ANN HERNANDEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 COORS BLVD NW
ALBUQUERQUE NM
87120-3699
US

IV. Provider business mailing address

2815 GUNNISON DR APT 201
COLUMBUS OH
43228-8985
US

V. Phone/Fax

Practice location:
  • Phone: 505-596-2200
  • Fax:
Mailing address:
  • Phone: 419-789-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2024-0005
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2024-0005
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: