Provider Demographics
NPI:1437745239
Name:HERNANDEZ, ELIDE (PTA)
Entity Type:Individual
Prefix:
First Name:ELIDE
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10076 SEDALIA ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-8744
Mailing Address - Country:US
Mailing Address - Phone:323-472-0408
Mailing Address - Fax:
Practice Address - Street 1:10076 SEDALIA ST
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-8744
Practice Address - Country:US
Practice Address - Phone:323-472-0408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-15
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0014819225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant