Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 0076069 | FL |
N | 207ND0101X | MOHS-Micrographic Surgeon | 0076069 | FL |
N | 207ND0900X | Dermatopathologist | 0076069 | FL |
N | 207NP0225X | Pediatric Dermatologist | 0076069 | FL |
N | 207NS0135X | Procedural Dermatology | 0076069 | FL |
NPI | 1609990605 |
---|---|
Provider Name | Manuel Hector Hernandez |
First Address | Punta Gorda, FL 33951-0065 |
Second Address | Port Charlotte, FL 33952-5306 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/03/2007 |
Last Update Date | 15/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
44353 | BLUE CROSS BLUE SHIELD (01) | FL |
G55294 | (02) | FL |