Provider Demographics
NPI:1649664244
Name:HERNANDEZ, MARK (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-2007
Mailing Address - Country:US
Mailing Address - Phone:512-426-3536
Mailing Address - Fax:
Practice Address - Street 1:3710 GILBERT ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-2007
Practice Address - Country:US
Practice Address - Phone:512-426-3536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096444225100000X
COPTL0010022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist