Provider Demographics
NPI:1689650434
Name:HEWITT, THOMAS (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:HEWITT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 LANKFORD ST
Mailing Address - Street 2:
Mailing Address - City:CLAY CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47841-1008
Mailing Address - Country:US
Mailing Address - Phone:812-939-2126
Mailing Address - Fax:812-939-3414
Practice Address - Street 1:315 LANKFORD ST
Practice Address - Street 2:
Practice Address - City:CLAY CITY
Practice Address - State:IN
Practice Address - Zip Code:47841-1008
Practice Address - Country:US
Practice Address - Phone:812-939-2126
Practice Address - Fax:812-939-3414
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000136A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN130910Medicare ID - Type UnspecifiedGROUP NUMBER