Basic Information
| Provider Information | |||||||||
| NPI: | 1366566689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | MIGUEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 32490 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850642490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022304478 | ||||||||
| FaxNumber: | 6022309962 | ||||||||
| Practice Location | |||||||||
| Address1: | 3050 N LITCHFIELD RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853957804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239355505 | ||||||||
| FaxNumber: | 6539355551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5127 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 252713 | 05 | AZ | MEDICAID |