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General NPI Number Information
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NPI Number | 1992765747
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Entity Type | Individual
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Provider Name | THOMAS GLEN HETTICH PA-C
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Gender | Male
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Dates
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Enumeration Date | 03/24/2006
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Last Update Date | 05/29/2025
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Provider Practice Location Address
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Address Line | 21044 FREDERICK RD
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City | GERMANTOWN
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State | MD
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Zip | 20876-4132
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Country | US
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Telephone | 240-238-5432
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Fax |
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Provider Business Mailing Address
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Address Line | 3534 DIAZ ST
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City | TRINITY
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State | FL
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Zip | 34655-2163
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Country | US
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Telephone | 727-644-2597
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9108323
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C0009860
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License Number State | MD
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