Provider Demographics
NPI:1174517528
Name:HERNANDEZ, MARY IRENE (MPT, CWS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:IRENE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MPT, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-267-4843
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-267-2233
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCB3544OtherTRAV RR GROUP PTAN NUMBER
OR297645Medicaid
ORP00317115OtherTRAV RR PTAN NUMBER
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR1407812365OtherMEDICARE GROUP NPI NUMBER
OR1407812365OtherMEDICARE GROUP NPI NUMBER
ORR134570Medicare PIN