Provider Demographics
NPI:1932110079
Name:HERNANDEZ, TIMOTHY J (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:234 WENTWORTH AVE E
Practice Address - Street 2:
Practice Address - City:WEST SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3525
Practice Address - Country:US
Practice Address - Phone:651-455-2940
Practice Address - Fax:651-455-3354
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-04-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN30114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN189882500Medicaid
MN189882500Medicaid