Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | H655-00-76-783-0 | FL |
NPI | 1205337623 |
---|---|
Provider Name | Amalia Hernandez |
First Address | Davie, FL 33324-4230 |
Second Address | Davie, FL 33324-4230 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2018 |
Last Update Date | 21/02/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PGQ167M89290 | (05) | FL |