Provider Demographics
NPI:1295169001
Name:HAWTHORNE, DERRAL EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:DERRAL
Middle Name:EDWARD
Last Name:HAWTHORNE
Suffix:
Gender:
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 1:94180 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GOLD BEACH
Mailing Address - State:OR
Mailing Address - Zip Code:97444-8733
Mailing Address - Country:US
Mailing Address - Phone:541-247-3940
Mailing Address - Fax:541-247-3116
Practice Address - Street 1:94180 2ND ST
Practice Address - Street 2:
Practice Address - City:GOLD BEACH
Practice Address - State:OR
Practice Address - Zip Code:97444-8733
Practice Address - Country:US
Practice Address - Phone:541-247-7047
Practice Address - Fax:541-247-0123
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA191287363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant