Provider Demographics
NPI:1104248798
Name:MAHATHA, HAZEL G (DNP)
Entity type:Individual
Prefix:DR
First Name:HAZEL
Middle Name:G
Last Name:MAHATHA
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 PORTA ROSA CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0495
Mailing Address - Country:US
Mailing Address - Phone:907-230-9686
Mailing Address - Fax:
Practice Address - Street 1:1600 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5622
Practice Address - Country:US
Practice Address - Phone:915-599-6670
Practice Address - Fax:915-775-0549
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10187-33363L00000X, 363LP0808X
TXAP132207363LP0808X
AZAP10720363LP0808X
TN18267363LP0808X
FL9403701363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner