Healthcare Provider Details

I. General information

NPI: 1992765747
Provider Name (Legal Business Name): THOMAS GLEN HETTICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21044 FREDERICK RD
GERMANTOWN MD
20876-4132
US

IV. Provider business mailing address

3534 DIAZ ST
TRINITY FL
34655-2163
US

V. Phone/Fax

Practice location:
  • Phone: 240-238-5432
  • Fax:
Mailing address:
  • Phone: 727-644-2597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9108323
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009860
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: