Healthcare Provider Details

I. General information

NPI: 1497283030
Provider Name (Legal Business Name): PAUL W HLAVINKA CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 BRODHEAD RD
BETHLEHEM PA
18017-8931
US

IV. Provider business mailing address

153 BRODHEAD RD
BETHLEHEM PA
18017-8931
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-3218
  • Fax: 484-526-3180
Mailing address:
  • Phone: 484-526-3218
  • Fax: 484-526-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP017592
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: