Provider Demographics
NPI:1992867535
Name:HERNANDEZ, EDWARD FIDEL (RN)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:FIDEL
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:CA
Mailing Address - Zip Code:94706-1106
Mailing Address - Country:US
Mailing Address - Phone:707-536-3077
Mailing Address - Fax:707-536-3077
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806-3305
Practice Address - Country:US
Practice Address - Phone:510-215-3730
Practice Address - Fax:510-215-3731
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA387107163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA387107OtherREGISTERED NURSE LICENSE