Provider Demographics
NPI:1578742201
Name:HERNANDEZ, PABLO ANTONIO (PA)
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:ANTONIO
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-5053
Mailing Address - Country:US
Mailing Address - Phone:305-345-4262
Mailing Address - Fax:
Practice Address - Street 1:721 NW 21ST CT
Practice Address - Street 2:SUITE100
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3434
Practice Address - Country:US
Practice Address - Phone:786-310-7115
Practice Address - Fax:786-464-5125
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9100127OtherPHYSICIAN ASSISTANCE