Provider Demographics
NPI:1366566689
Name:HERNANDEZ, MIGUEL R (PT)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:R
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32490
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-2490
Mailing Address - Country:US
Mailing Address - Phone:602-230-4478
Mailing Address - Fax:602-230-9962
Practice Address - Street 1:3050 N LITCHFIELD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-7804
Practice Address - Country:US
Practice Address - Phone:623-935-5505
Practice Address - Fax:653-935-5551
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ252713Medicaid
AZ252713Medicaid