Provider Demographics
NPI:1154133320
Name:HERNANDEZ, KEVIN (PTA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 PARK AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-3448
Mailing Address - Country:US
Mailing Address - Phone:848-203-1206
Mailing Address - Fax:
Practice Address - Street 1:25919 GADING RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-2725
Practice Address - Country:US
Practice Address - Phone:510-782-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00407600225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant