Basic Information
| Provider Information | |||||||||
| NPI: | 1649212762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HERNANDEZ | ||||||||
| OtherFirstName: | AL | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 315 75TH ST W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342093201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417611998 | ||||||||
| FaxNumber: | 9417488484 | ||||||||
| Practice Location | |||||||||
| Address1: | 4110 MANATEE AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342051719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417488383 | ||||||||
| FaxNumber: | 9417488484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT7722 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y6294 | 01 | FL | BCBS INDIV PROV NUM | OTHER | 2103654 | 01 | FL | FIRST HEALTH INDIV PROV # | OTHER | 890853200 | 05 | FL | MEDICAID |