Provider Demographics
NPI:1275503518
Name:HERNANDEZ, JOHN M (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23550 HAGGERTY RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2614
Mailing Address - Country:US
Mailing Address - Phone:248-381-8081
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:23550 HAGGERTY RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-2614
Practice Address - Country:US
Practice Address - Phone:248-381-8081
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601001163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP29268Medicare UPIN