Provider Demographics
NPI:1316591324
Name:HACKENBERG, JOSHUA (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:HACKENBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 N ASHLEY DR UNIT 2007
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4375
Mailing Address - Country:US
Mailing Address - Phone:570-490-7195
Mailing Address - Fax:
Practice Address - Street 1:777 N ASHLEY DR UNIT 2007
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4375
Practice Address - Country:US
Practice Address - Phone:570-490-7195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-29
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112319363A00000X
FLPA9112319363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant