Provider Demographics
NPI:1730514761
Name:HERNANDEZ, LYDIA MAE (PTA)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:MAE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:MAE
Other - Last Name:KANTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2400 SKYLINE BLVD
Mailing Address - Street 2:APT G4
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044
Mailing Address - Country:US
Mailing Address - Phone:415-336-4618
Mailing Address - Fax:
Practice Address - Street 1:2400 SKYLINE BLVD
Practice Address - Street 2:APT G4
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044
Practice Address - Country:US
Practice Address - Phone:415-336-4618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6500225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant