Provider Demographics
NPI:1740904168
Name:HERNANDEZ, LYSANDRA (PA)
Entity type:Individual
Prefix:
First Name:LYSANDRA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CALLE SAMARIA 924
Mailing Address - Street 2:VILLA DEL CARMEN
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00716
Mailing Address - Country:US
Mailing Address - Phone:787-234-2808
Mailing Address - Fax:
Practice Address - Street 1:909 AVE TITO CASTRO STE 510
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4721
Practice Address - Country:US
Practice Address - Phone:787-259-7293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR392PA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical