Healthcare Provider Details

I. General information

NPI: 1730400870
Provider Name (Legal Business Name): JESUS HERNANDEZ CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E LISA DR
CHAPARRAL NM
88081
US

IV. Provider business mailing address

385 CALLE DE ALEGRA BLDG. A
LAS CRUCES NM
88005-3417
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-0820
  • Fax: 575-824-1021
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-01621
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: