Provider Demographics
NPI:1760670202
Name:HERNANDEZ, EDISON (PT)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4774 AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-6304
Mailing Address - Country:US
Mailing Address - Phone:727-798-6395
Mailing Address - Fax:
Practice Address - Street 1:4774 AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-6304
Practice Address - Country:US
Practice Address - Phone:727-798-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 9050225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist