Provider Demographics
NPI:1992375554
Name:HATHCOCK, SAMUEL GORDON (PA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GORDON
Last Name:HATHCOCK
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 1:4645 NW 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4687
Mailing Address - Country:US
Mailing Address - Phone:352-375-1212
Mailing Address - Fax:352-371-4650
Practice Address - Street 1:410 CELEBRATION PL STE 300
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5434
Practice Address - Country:US
Practice Address - Phone:407-894-4474
Practice Address - Fax:407-894-7032
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-008149363A00000X
FLPA9116218363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110-008149OtherVIRGINIA BOARD OF MEDICINE LICENSE