Provider Demographics
NPI:1982177986
Name:HERNANDEZ-LUCIO, MITCHELL (LSA)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:HERNANDEZ-LUCIO
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25134 BUTTERWICK DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-3339
Mailing Address - Country:US
Mailing Address - Phone:713-578-0697
Mailing Address - Fax:
Practice Address - Street 1:25134 BUTTERWICK DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77389-3339
Practice Address - Country:US
Practice Address - Phone:713-578-0697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00801363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical