Provider Demographics
NPI:1326774183
Name:HERNANDEZ, MARIO A
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:A
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 1:1124 PIERCE DR APT 7
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1559
Mailing Address - Country:US
Mailing Address - Phone:559-726-3922
Mailing Address - Fax:
Practice Address - Street 1:258 N BLACKSTONE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-1913
Practice Address - Country:US
Practice Address - Phone:669-274-0299
Practice Address - Fax:844-606-7326
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1326774183172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker