Provider Demographics
NPI:1831960699
Name:ORTEGA HERNANDEZ, JORGE (PA)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:ORTEGA HERNANDEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6508 W ALTADENA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-3115
Mailing Address - Country:US
Mailing Address - Phone:786-470-6495
Mailing Address - Fax:
Practice Address - Street 1:6508 W ALTADENA AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-3115
Practice Address - Country:US
Practice Address - Phone:786-470-6495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2020363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical