Provider Demographics
NPI:1427047240
Name:HAWK, KENNETH W (NP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:HAWK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21550-1371
Mailing Address - Country:US
Mailing Address - Phone:301-334-7420
Mailing Address - Fax:301-334-1819
Practice Address - Street 1:311 N 4TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MD
Practice Address - Zip Code:21550-1371
Practice Address - Country:US
Practice Address - Phone:301-334-7420
Practice Address - Fax:301-334-1819
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV57454363LF0000X
MDR167958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810001587Medicaid
Q34403Medicare UPIN
WVP00193301Medicare PIN
2025877Medicare PIN
WV2025876Medicare PIN