Provider Demographics
NPI:1730400870
Name:HERNANDEZ, JESUS (CNP)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 CALLE DE ALEGRA
Mailing Address - Street 2:BLDG. A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3417
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:510 E LISA DR
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081
Practice Address - Country:US
Practice Address - Phone:575-824-0820
Practice Address - Fax:575-824-1021
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28820533Medicaid
NMNMA100721OtherMEDICARE