Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0401X | Family Doctor - Addiction Medicine | ME83014 | FL |
NPI | 1417407958 |
---|---|
Provider Name | Mr. Rafael Hernandez JR. |
First Address | Port Saint Lucie, FL 34952-5606 |
Second Address | Port Saint Lucie, FL 34952-5606 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/10/2016 |
Last Update Date | 07/10/2016 |