Provider Demographics
NPI:1295163152
Name:FERNANDEZ DE CORDOVA, HAYLEY LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HAYLEY
Middle Name:LYNN
Last Name:FERNANDEZ DE CORDOVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HAYLEY
Other - Middle Name:LYNN
Other - Last Name:LANGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3001 N MAIN ST
Mailing Address - Street 2:STE 1C
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-1215
Mailing Address - Country:US
Mailing Address - Phone:872-588-3000
Mailing Address - Fax:
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-30
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant