Provider Demographics
NPI:1134887029
Name:HERNANDEZ, JED PATRICK
Entity type:Individual
Prefix:
First Name:JED
Middle Name:PATRICK
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1088 OHIO AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3662
Mailing Address - Country:US
Mailing Address - Phone:310-408-3951
Mailing Address - Fax:
Practice Address - Street 1:1088 OHIO AVE APT 2
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3662
Practice Address - Country:US
Practice Address - Phone:310-408-3951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-07
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA363A00000X
CA60927363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant