Basic Information
Provider Information | |||||||||
NPI: | 1023299864 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERNANDEZ HOLMES | ||||||||
FirstName: | VERA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C, RD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HERNANDEZ | ||||||||
OtherFirstName: | VERA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RD, LDN, CNSD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9 INDUSTRIAL RD STE 5 | ||||||||
Address2: |   | ||||||||
City: | MILFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 017573736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084731480 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 14 PROSPECT ST | ||||||||
Address2: |   | ||||||||
City: | MILFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 017573003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084731190 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2007 | ||||||||
LastUpdateDate: | 10/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2635 | MA | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 363AM0700X | PA4830 | MA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1023299864 | 01 | MA | NPI | OTHER | PA4830 | 01 | MA | PHYSICIAN ASSISTANT LICENSE | OTHER |