Basic Information
| Provider Information | |||||||||
| NPI: | 1124088448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | CATHLEEN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032971419 | ||||||||
| FaxNumber: | 5032162488 | ||||||||
| Practice Location | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032971419 | ||||||||
| FaxNumber: | 5032162488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA17443 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA01239 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 00PA174430 | 05 | CA | MEDICAID |