Provider Demographics
NPI:1558857003
Name:HERNANDEZ, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
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 1:256 W HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1528
Mailing Address - Country:US
Mailing Address - Phone:626-354-0096
Mailing Address - Fax:
Practice Address - Street 1:7101 BAIRD AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4150
Practice Address - Country:US
Practice Address - Phone:818-342-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty