MEDICARE: MRS. MARICELA HERNANDEZ LSA

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	363AS0400X	Surgical Physician Assistant	SA00244	TX

General Provider Information

NPI Number	:	1851558985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARICELA HERNANDEZ LSA

Provider Business Mailing Address
First Line	:	14027 MEMORIAL DR STE 120
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-6826
Country	:	US
Telephone Number	:	832-863-2057
Fax Number	:	281-558-2756

Provider Business Practice Location Address
First Line	:	14027 MEMORIAL DR STE 120
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-6826
Country	:	US
Telephone Number	:	832-863-2057
Fax Number	:	281-558-2756

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

Provider Enumeration Date	:	05/16/2008
Last Update Date	:	02/10/2015

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