Provider Demographics
NPI:1801223912
Name:HERNANDEZ, MARK ANDREW (LAC)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2113 RICHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-7117
Mailing Address - Country:US
Mailing Address - Phone:469-867-1841
Mailing Address - Fax:
Practice Address - Street 1:4525 LEMMON AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2145
Practice Address - Country:US
Practice Address - Phone:469-867-1841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01388171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist