Provider Demographics
NPI:1336477124
Name:HAWK, NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HAWK
Suffix:
Gender:F
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 1:1210 ROUTE 130 N
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-3046
Mailing Address - Country:US
Mailing Address - Phone:856-829-0407
Mailing Address - Fax:
Practice Address - Street 1:1210 ROUTE 130 N
Practice Address - Street 2:
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-3046
Practice Address - Country:US
Practice Address - Phone:856-829-0407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-07
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054181363A00000X
NJ25MP00275100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant