Healthcare Provider Details

I. General information

NPI: 1245976125
Provider Name (Legal Business Name): SAMUEL HAWKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 N 5TH STREET HWY
READING PA
19605-2427
US

IV. Provider business mailing address

2004 ARCH STREET EXT
BROCKWAY PA
15824-8018
US

V. Phone/Fax

Practice location:
  • Phone: 814-715-6169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS043751
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: