Provider Demographics
NPI:1295159796
Name:HERNANDEZ, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
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 1:3216 SW 11TH AVE APT B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1480 NE VILLAGE ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-3827
Practice Address - Country:US
Practice Address - Phone:503-489-6250
Practice Address - Fax:503-489-1650
Is Sole Proprietor?:No
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist