Provider Demographics
NPI:1801501861
Name:HERMENEGILDO, IRIDIANA
Entity type:Individual
Prefix:
First Name:IRIDIANA
Middle Name:
Last Name:HERMENEGILDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S LAGUNA ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93292-3680
Mailing Address - Country:US
Mailing Address - Phone:209-676-1807
Mailing Address - Fax:
Practice Address - Street 1:115 MALL DR
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5786
Practice Address - Country:US
Practice Address - Phone:559-582-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-13
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363AM0700X
CA62281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical