Provider Demographics
NPI:1982223244
Name:HAWKINS, KEITH (CFSA, CSA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:HAWKINS
Suffix:
Gender:M
Credentials:CFSA, CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 871063
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0027
Mailing Address - Country:US
Mailing Address - Phone:225-810-7571
Mailing Address - Fax:
Practice Address - Street 1:8498 GLENVIEW ST
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5639
Practice Address - Country:US
Practice Address - Phone:225-810-7571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
GA18-356246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty