Provider Demographics
NPI:1821248303
Name:HETTLER, ERIC I (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:I
Last Name:HETTLER
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 1:5245 WALZEM RD
Mailing Address - Street 2:
Mailing Address - City:WINDCREST
Mailing Address - State:TX
Mailing Address - Zip Code:78218-2122
Mailing Address - Country:US
Mailing Address - Phone:210-654-9700
Mailing Address - Fax:
Practice Address - Street 1:5245 WALZEM RD
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78218-2122
Practice Address - Country:US
Practice Address - Phone:210-654-9700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05495363A00000X
TX1077591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB153728Medicare Oscar/Certification