Provider Demographics
NPI:1528713369
Name:HERNANDEZ, KRYSTINA (PA-C)
Entity type:Individual
Prefix:
First Name:KRYSTINA
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5060 SEA REEF PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-8430
Mailing Address - Country:US
Mailing Address - Phone:402-312-9816
Mailing Address - Fax:
Practice Address - Street 1:1832 ALPINE BLVD
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-2107
Practice Address - Country:US
Practice Address - Phone:619-326-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant