Provider Demographics
NPI:1285215798
Name:HERNANDEZ, MICHAEL ESTEBAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ESTEBAN
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 E 100 S
Mailing Address - Street 2:
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-5443
Mailing Address - Country:US
Mailing Address - Phone:208-219-3367
Mailing Address - Fax:
Practice Address - Street 1:3560 E FLAMINGO RD STE 100
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5088
Practice Address - Country:US
Practice Address - Phone:702-433-6944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant