Healthcare Provider Details

I. General information

NPI: 1174557680
Provider Name (Legal Business Name): SUSAN LYNN HACKWORTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 BROWNSVILLE RD
PITTSBURGH PA
15227-3520
US

IV. Provider business mailing address

3720 BROWNSVILLE RD
PITTSBURGH PA
15227-3520
US

V. Phone/Fax

Practice location:
  • Phone: 412-882-9455
  • Fax: 412-884-6149
Mailing address:
  • Phone: 412-882-9455
  • Fax: 412-884-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA 002831L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: