Basic Information
| Provider Information | |||||||||
| NPI: | 1447731237 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERNANDES PINEDA | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | MANUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9537 GRAVELLY LAKE DR SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984991513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539842000 | ||||||||
| FaxNumber: | 2538159797 | ||||||||
| Practice Location | |||||||||
| Address1: | 9537 GRAVELLY LAKE DR SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984991513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539842000 | ||||||||
| FaxNumber: | 2538159797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2018 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363AM0700X | PA61012242 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2147900 | 05 | WA | MEDICAID |