Basic Information
Provider Information
NPI: 1174093793
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HERNANDEZ
FirstName: NEFTALI
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 213 5TH ST
Address2:  
City: ROSEVILLE
State: CA
PostalCode: 956783904
CountryCode: US
TelephoneNumber: 9163472164
FaxNumber:  
Practice Location
Address1: 8801 FOLSOM BLVD STE 265
Address2:  
City: SACRAMENTO
State: CA
PostalCode: 958263250
CountryCode: US
TelephoneNumber: 9163824447
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/26/2018
LastUpdateDate: 12/28/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 12/28/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

ID Information
IDTypeStateIssuerDescription
0141747801 KAISER PERMANENTEOTHER


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