Basic Information
Provider Information
NPI: 1003000720
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HERNANDEZ
FirstName: OTNIEL
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DNP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1275 W 47TH PL
Address2: SUITE 422
City: HIALEAH
State: FL
PostalCode: 33012
CountryCode: US
TelephoneNumber: 3056762300
FaxNumber: 8886010076
Practice Location
Address1: 1275 W 47TH PL
Address2: SUITE 422
City: HIALEAH
State: FL
PostalCode: 330123394
CountryCode: US
TelephoneNumber: 3056762300
FaxNumber: 8886010076
Other Information
ProviderEnumerationDate: 09/06/2007
LastUpdateDate: 05/03/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000XARNP3081082FLY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

ID Information
IDTypeStateIssuerDescription
30861430005FL MEDICAID


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