Provider Demographics
NPI:1518625797
Name:HERNANDEZ REYES, LAURO
Entity Type:Individual
Prefix:
First Name:LAURO
Middle Name:
Last Name:HERNANDEZ REYES
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 1:508 N IMPERIAL AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4089
Mailing Address - Country:US
Mailing Address - Phone:845-300-2785
Mailing Address - Fax:
Practice Address - Street 1:905 N EMILY ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-1910
Practice Address - Country:US
Practice Address - Phone:845-300-2785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMTA45076246Q00000X
NY014675-1246Q00000X
CA836385163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology