Provider Demographics
NPI:1639486178
Name:HERNANDEZ, MATTHEW (CSW)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-0518
Mailing Address - Country:US
Mailing Address - Phone:505-865-3350
Mailing Address - Fax:505-865-4739
Practice Address - Street 1:4011 BARBARA LOOP SE STE 207
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1041
Practice Address - Country:US
Practice Address - Phone:505-865-3350
Practice Address - Fax:505-865-4739
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44842Medicaid