Provider Demographics
NPI:1568123073
Name:HERNANDEZ-GALVAN, JOSE ANDRES
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANDRES
Last Name:HERNANDEZ-GALVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANDRES
Other - Middle Name:
Other - Last Name:DE LA ROSA-HERNANDEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:246 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:246 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3444
Practice Address - Country:US
Practice Address - Phone:458-201-2740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000104655OtherOHA - TRADITIONAL HEALTH WORKER