Basic Information
| Provider Information | |||||||||
| NPI: | 1003000720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | OTNIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601843 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601843 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3163 GAMMON LN STE 422 | ||||||||
| Address2: | |||||||||
| City: | CLEMMONS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 270129052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363105571 | ||||||||
| FaxNumber: | 3363105574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2007 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP3081082 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5012043 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 308614300 | 05 | FL | MEDICAID |