MEDICARE: AGNES PARDO HERNANDEZ SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician	RBT-23-298842	FL

General Provider Information

NPI Number	:	1811779077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGNES PARDO HERNANDEZ SR.

Provider Business Mailing Address
First Line	:	2658 MESQUITE AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-7418
Country	:	US
Telephone Number	:	904-444-7655
Fax Number	:

Provider Business Practice Location Address
First Line	:	2658 MESQUITE AVE
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32065-7418
Country	:	US
Telephone Number	:	904-444-7655
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2023
Last Update Date	:	10/20/2023

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