Healthcare Provider Details

I. General information

NPI: 1497121545
Provider Name (Legal Business Name): JONATHAN HERNANDEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2015
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 N TENAYA WAY
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 702-877-5199
  • Fax: 858-258-6741
Mailing address:
  • Phone: 702-383-6210
  • Fax: 858-258-6741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9108887
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2882
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: