Provider Demographics
NPI:1073088225
Name:HERNANDEZ, WALTER ERNESTO (FNP)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:ERNESTO
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 PALM AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2348
Mailing Address - Country:US
Mailing Address - Phone:951-565-6835
Mailing Address - Fax:
Practice Address - Street 1:9415 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-2661
Practice Address - Country:US
Practice Address - Phone:951-360-8795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009823363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily