Provider Demographics
NPI:1508565573
Name:HERNANDEZ, JOSE ANTONIO
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
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 1:441 N GRAND AVE STE 17
Mailing Address - Street 2:
Mailing Address - City:NOGALES
Mailing Address - State:AZ
Mailing Address - Zip Code:85621-2729
Mailing Address - Country:US
Mailing Address - Phone:520-500-7571
Mailing Address - Fax:520-287-0060
Practice Address - Street 1:441 N GRAND AVE STE 17
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-2729
Practice Address - Country:US
Practice Address - Phone:520-500-7571
Practice Address - Fax:520-287-0060
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)