Provider Demographics
NPI:1477221596
Name:HERNANDEZ, MARCO (COTA)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3191 WINDING TRL
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2812
Mailing Address - Country:US
Mailing Address - Phone:954-812-1052
Mailing Address - Fax:
Practice Address - Street 1:1200 N CENTRAL AVE STE 110
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4439
Practice Address - Country:US
Practice Address - Phone:407-201-7429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18542224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant