Basic Information
| Provider Information | |||||||||
| NPI: | 1992867535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNANDEZ | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | FIDEL | ||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947061106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075363077 | ||||||||
| FaxNumber: | 7075363077 | ||||||||
| Practice Location | |||||||||
| Address1: | 2523 EL PORTAL DR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SAN PABLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948063305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102153730 | ||||||||
| FaxNumber: | 5102153731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 09/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 387107 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 387107 | 01 | CA | REGISTERED NURSE LICENSE | OTHER |