Provider Demographics
NPI:1447731237
Name:HERNANDES PINEDA, VICTOR MANUEL
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
Last Name:HERNANDES PINEDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9537 GRAVELLY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1513
Mailing Address - Country:US
Mailing Address - Phone:253-984-2000
Mailing Address - Fax:253-815-9797
Practice Address - Street 1:9537 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1513
Practice Address - Country:US
Practice Address - Phone:253-984-2000
Practice Address - Fax:253-815-9797
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAPA61012242363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2147900Medicaid