Provider Demographics
NPI:1407684533
Name:DESTRADE HERNANDEZ, RICHARD SR (PA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:DESTRADE HERNANDEZ
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1847 W HEATHERBRAE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4764
Mailing Address - Country:US
Mailing Address - Phone:602-274-2100
Mailing Address - Fax:602-535-3166
Practice Address - Street 1:1847 W HEATHERBRAE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4764
Practice Address - Country:US
Practice Address - Phone:602-274-2100
Practice Address - Fax:602-535-3166
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ10419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant