Provider Demographics
NPI:1598390452
Name:HERNANDEZ, RAYMOND L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:L
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DAY LILLY WAY
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31315-1017
Mailing Address - Country:US
Mailing Address - Phone:580-583-8173
Mailing Address - Fax:
Practice Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:650 JOEL DRIVE
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5349
Practice Address - Country:US
Practice Address - Phone:270-798-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
1174434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program