Provider Demographics
NPI:1407211634
Name:HERNANDEZ, HAZLETT (PT,DPT)
Entity Type:Individual
Prefix:
First Name:HAZLETT
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17332 VON KARMAN AVE
Mailing Address - Street 2:#120
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17332 VON KARMAN AVE
Practice Address - Street 2:#120
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6242
Practice Address - Country:US
Practice Address - Phone:949-861-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist