1992765747 NPI number — MR. THOMAS GLEN HETTICH PA-C

Table of content: MR. THOMAS GLEN HETTICH PA-C (NPI 1992765747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992765747 NPI number — MR. THOMAS GLEN HETTICH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HETTICH
Provider First Name:
THOMAS
Provider Middle Name:
GLEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992765747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3534 DIAZ ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRINITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34655-2163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-644-2597
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3250 ZEMKE AVE
Provider Second Line Business Practice Location Address:
ATTN: SOCCENT CLINIC
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33621-5023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-827-9213
Provider Business Practice Location Address Fax Number:
813-827-1319
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9108323 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1049243 . This is a "NCCPA CERTIFICATION NUM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 014685300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com