Healthcare Provider Details

I. General information

NPI: 1215104526
Provider Name (Legal Business Name): NATHANAEL L HAWKINS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

IV. Provider business mailing address

5408 BLUE DOG RD
PANAMA CITY FL
32404-6031
US

V. Phone/Fax

Practice location:
  • Phone: 850-638-1610
  • Fax:
Mailing address:
  • Phone: 850-768-0161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTRN12420
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: