Provider Demographics
NPI:1467172619
Name:HERNANDEZ, CRISTIAN LEE
Entity Type:Individual
Prefix:
First Name:CRISTIAN
Middle Name:LEE
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 1:5205 GAINES ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73135-1427
Mailing Address - Country:US
Mailing Address - Phone:405-404-5042
Mailing Address - Fax:
Practice Address - Street 1:526 SW 4TH ST STE 200
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5409
Practice Address - Country:US
Practice Address - Phone:405-759-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3266225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3266OtherMEDICAL LICENSE NUMBER