Provider Demographics
NPI:1902274145
Name:HERNANDEZ, RICARDO JR
Entity Type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:
Last Name:HERNANDEZ
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3462 E CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-1219
Mailing Address - Country:US
Mailing Address - Phone:602-810-1666
Mailing Address - Fax:
Practice Address - Street 1:3462 E CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-1219
Practice Address - Country:US
Practice Address - Phone:602-810-1666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25444944246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory