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General NPI Number Information
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NPI Number | 1457416224
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Entity Type | Individual
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Provider Name | MARK EDWARD HERNANDEZ M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/22/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 302 S 1ST AVE
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City | SANDPOINT
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State | ID
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Zip | 83864-1258
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Country | US
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Telephone | 208-263-5109
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Fax | 208-263-5112
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Provider Business Mailing Address
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Address Line | 290 PONDER POINT DR
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City | SANDPOINT
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State | ID
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Zip | 83864-8657
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Country | US
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Telephone | 208-263-1588
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Fax | 208-263-5112
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | M6092
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License Number State | ID
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