Provider Demographics
NPI:1255597993
Name:HANTL, JUDITH ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:ANNE
Last Name:HANTL
Suffix:
Gender:F
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 1:13109 TITLEIST DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34669-2411
Mailing Address - Country:US
Mailing Address - Phone:727-856-2357
Mailing Address - Fax:
Practice Address - Street 1:13109 TITLEIST DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34669-2411
Practice Address - Country:US
Practice Address - Phone:727-856-2357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10236RX363A00000X
VA0110003216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAA10236RXOtherLA STATE LICENSE
LA1332402Medicaid
LA1332402Medicaid
LA53202P398Medicare PIN