Provider Demographics
NPI:1851345201
Name:HAWKINS, THERON D (PAC)
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:D
Last Name:HAWKINS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6615
Mailing Address - Country:US
Mailing Address - Phone:727-734-4000
Mailing Address - Fax:727-734-4454
Practice Address - Street 1:703 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6615
Practice Address - Country:US
Practice Address - Phone:727-734-4000
Practice Address - Fax:727-734-4454
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101296363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY00YEOtherBCBS
E6744PMedicare PIN
FLY00YEOtherBCBS