=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760283345
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY COOMER HERNANDEZ PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2025
-----------------------------------------------------
Last Update Date | 03/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5330 S HIGHWAY 95
-----------------------------------------------------
City | FORT MOHAVE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86426-9225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-788-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 533O S HWY 95
-----------------------------------------------------
City | FORT MOHAVE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 014942
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------