Provider Demographics
NPI:1417479205
Name:HERNANDEZ, RAFAEL GUADALUPE
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:GUADALUPE
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1358 DYNES ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-8410
Mailing Address - Country:US
Mailing Address - Phone:209-500-9678
Mailing Address - Fax:
Practice Address - Street 1:1358 DYNES ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-8410
Practice Address - Country:US
Practice Address - Phone:209-500-9678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1600058913343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)