Healthcare Provider Details

I. General information

NPI: 1609279298
Provider Name (Legal Business Name): AMY MARIE HERNANDEZ PA-C, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 RYAN DR SE
SALEM OR
97301-5057
US

IV. Provider business mailing address

875 OAK ST SE STE 4030
SALEM OR
97301-3984
US

V. Phone/Fax

Practice location:
  • Phone: 503-540-9999
  • Fax: 503-540-3105
Mailing address:
  • Phone: 503-561-6444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA169940
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: