Healthcare Provider Details

I. General information

NPI: 1962275586
Provider Name (Legal Business Name): JUAN CARLOS SANCHEZ HERNANDEZ SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11120 COUNTY ROAD 417
TYLER TX
75704-4040
US

IV. Provider business mailing address

11120 COUNTY ROAD 417
TYLER TX
75704-4040
US

V. Phone/Fax

Practice location:
  • Phone: 903-515-9669
  • Fax:
Mailing address:
  • Phone: 903-515-9669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number23-688
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: