Provider Demographics
NPI:1417251372
Name:HERNANDEZ, LUIS (PA)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 S 109TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5822
Mailing Address - Country:US
Mailing Address - Phone:918-392-1400
Mailing Address - Fax:918-392-1488
Practice Address - Street 1:4802 S 109TH EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5822
Practice Address - Country:US
Practice Address - Phone:918-392-1400
Practice Address - Fax:918-392-1488
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
OK1997363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist