Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 56635 | WI |
NPI | 1003059353 |
---|---|
Provider Name | Dr. Mary Grace Hernandez Lasquety |
First Address | Glendale, WI 53212-1082 |
Second Address | Milwaukee, WI 53211-4445 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2009 |
Last Update Date | 20/08/2015 |