Provider Demographics
NPI:1285210377
Name:HERNANDEZ, NICHOLAS JON
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JON
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 ALBANY ST # 2R
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2520
Mailing Address - Country:US
Mailing Address - Phone:617-638-6975
Mailing Address - Fax:617-638-6959
Practice Address - Street 1:750 ALBANY ST # 2R
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2520
Practice Address - Country:US
Practice Address - Phone:617-638-6975
Practice Address - Fax:617-638-6959
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program