Basic Information
| Provider Information | |||||||||
| NPI: | 1649857780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | ALYSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 EDGEGROVE AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103122858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187447866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125234000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2021 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.