Provider Demographics
NPI:1689358186
Name:HERNANDEZ, JUAN JOSE (PA-C, MS)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PA-C, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATT: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:700 W 800 N STE 100
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-6301
Practice Address - Country:US
Practice Address - Phone:801-373-7350
Practice Address - Fax:801-224-5337
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT13448852-1206363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant