Healthcare Provider Details

I. General information

NPI: 1508992322
Provider Name (Legal Business Name): VIRGINIA H HAWKER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8495 CRATER LAKE HWY
WHITE CITY OR
97503-3011
US

IV. Provider business mailing address

1474 SEVERSON DR
MEDFORD OR
97504-5654
US

V. Phone/Fax

Practice location:
  • Phone: 541-826-2111
  • Fax:
Mailing address:
  • Phone: 541-773-7207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: