Provider Demographics
NPI:1700135340
Name:HAWKES, BLAINE
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:
Last Name:HAWKES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:469 PARK TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3211
Mailing Address - Country:US
Mailing Address - Phone:208-969-9956
Mailing Address - Fax:208-957-5334
Practice Address - Street 1:50 S HIGHWAY 93
Practice Address - Street 2:
Practice Address - City:SHOSHONE
Practice Address - State:ID
Practice Address - Zip Code:83352-5337
Practice Address - Country:US
Practice Address - Phone:801-942-3311
Practice Address - Fax:801-495-5303
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8394301-8016225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist