Healthcare Provider Details

I. General information

NPI: 1104373950
Provider Name (Legal Business Name): JOSE SANTOS HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 330 KM 5.2 ROSARIO
SAN GERMAN PR
00681-0292
US

IV. Provider business mailing address

PO BOX 1810 PMB 292
MAYAGUEZ PR
00681-0292
US

V. Phone/Fax

Practice location:
  • Phone: 787-235-8520
  • Fax:
Mailing address:
  • Phone: 787-235-8520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: