Healthcare Provider Details

I. General information

NPI: 1427578889
Provider Name (Legal Business Name): SHANDA LEIGH HERNANDEZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 11TH ST
WICHITA FALLS TX
76301-4322
US

IV. Provider business mailing address

5201 CENTRAL FWY APT 304
WICHITA FALLS TX
76306-1381
US

V. Phone/Fax

Practice location:
  • Phone: 940-687-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: