Healthcare Provider Details

I. General information

NPI: 1073682720
Provider Name (Legal Business Name): NATHAN C HAWKES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

1618 TUCKER LN
ENCINITAS CA
92024-2924
US

V. Phone/Fax

Practice location:
  • Phone: 800-731-1394
  • Fax:
Mailing address:
  • Phone: 760-436-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD61036369
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01062671A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: