Provider Demographics
NPI:1982208716
Name:HERNANDEZ, SALVADOR
Entity type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 BRISTOL WAY
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-3007
Mailing Address - Country:US
Mailing Address - Phone:816-785-9587
Mailing Address - Fax:
Practice Address - Street 1:904 S 10TH ST STE A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64503-2400
Practice Address - Country:US
Practice Address - Phone:816-233-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MO2025009025363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician