Provider Demographics
NPI:1205861192
Name:HETZEL, BERNADETTE (PAC)
Entity Type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:
Last Name:HETZEL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2761 W EDISON PL
Mailing Address - Street 2:
Mailing Address - City:CITRUS SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34433-6115
Mailing Address - Country:US
Mailing Address - Phone:352-422-5926
Mailing Address - Fax:
Practice Address - Street 1:SEVEN RIVERS EMERGENCY DEPT
Practice Address - Street 2:6201 N. SUNCOAST BLVD
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428
Practice Address - Country:US
Practice Address - Phone:352-795-8348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101821363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292303300Medicaid
FLP41432Medicare UPIN