Healthcare Provider Details

I. General information

NPI: 1639161078
Provider Name (Legal Business Name): MICHAEL C HAWKINS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 11/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 ANTELOPE DRIVE STE 225
LAYTON UT
84041
US

IV. Provider business mailing address

1660 W ANTELOPE DR STE 225
LAYTON UT
84041-1167
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-0312
  • Fax: 801-479-0312
Mailing address:
  • Phone: 801-479-0312
  • Fax: 801-479-0312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number500991-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: