Provider Demographics
NPI:1043278047
Name:HERNANDEZ, LISA ROSE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ROSE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 PRESLEY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-3239
Mailing Address - Country:US
Mailing Address - Phone:718-984-0969
Mailing Address - Fax:718-984-4097
Practice Address - Street 1:6 PRESLEY ST
Practice Address - Street 2:ARBOR MEDICAL
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10308-3239
Practice Address - Country:US
Practice Address - Phone:718-984-0969
Practice Address - Fax:718-984-4097
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166698207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01152249Medicaid
WEL481Medicare ID - Type UnspecifiedGROUP
E44808Medicare UPIN
42F452Medicare ID - Type Unspecified