Healthcare Provider Details

I. General information

NPI: 1336228576
Provider Name (Legal Business Name): JOHN A HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 COTTAGE RD
CARTHAGE TX
75633-1466
US

IV. Provider business mailing address

PO BOX 549
CARTHAGE TX
75633-0549
US

V. Phone/Fax

Practice location:
  • Phone: 903-693-3841
  • Fax: 903-694-4633
Mailing address:
  • Phone: 903-693-3841
  • Fax: 903-694-4633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number222941
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: