=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255185385
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRVIN HERNANDEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 841 STERLING PKWY
-----------------------------------------------------
City | LINCOLN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95648-7324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-645-3388
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 BICENTENNIAL CIR APT 43
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95826-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-402-1025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA65367
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------