Provider Demographics
NPI:1689894784
Name:HERNANDEZ, JESUS A (NP)
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:A
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWTHORNE LANE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204
Mailing Address - Country:US
Mailing Address - Phone:704-384-6296
Mailing Address - Fax:704-384-6533
Practice Address - Street 1:200 HAWTHORNE LANE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-384-6296
Practice Address - Fax:704-384-6533
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201059363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily