Healthcare Provider Details

I. General information

NPI: 1023528825
Provider Name (Legal Business Name): MR. NIKOLAS ANTHONY HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8815 S TACOMA WAY STE 122
LAKEWOOD WA
98499-7011
US

IV. Provider business mailing address

4007 FAWCETT AVE
TACOMA WA
98418-6632
US

V. Phone/Fax

Practice location:
  • Phone: 253-682-0320
  • Fax:
Mailing address:
  • Phone: 253-678-2535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: