Provider Demographics
NPI:1013987379
Name:HERNANDEZ, MARYLOU (PA-C)
Entity type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8202 134TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-5938
Mailing Address - Country:US
Mailing Address - Phone:206-459-2847
Mailing Address - Fax:
Practice Address - Street 1:8202 134TH ST SE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98296-5938
Practice Address - Country:US
Practice Address - Phone:206-459-2847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004360363A00000X
NY013704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0163636OtherDEPT. OF LABOR & INDUSTRI
WA0515HEOtherREGENCE BLUE SHIELD NUMBE
WA8353773Medicaid
WAAB32859Medicare ID - Type UnspecifiedMEDICARE NUMBER
WA0163636OtherDEPT. OF LABOR & INDUSTRI
WA0515HEOtherREGENCE BLUE SHIELD NUMBE
WAG8868130Medicare PIN