Provider Demographics
NPI:1912138512
Name:MCCABE, HAZELINE KATHERINE (PA)
Entity type:Individual
Prefix:
First Name:HAZELINE
Middle Name:KATHERINE
Last Name:MCCABE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HAZELINE
Other - Middle Name:KATHERINE
Other - Last Name:CAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:STE 150
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3233
Practice Address - Country:US
Practice Address - Phone:904-242-7177
Practice Address - Fax:904-242-7433
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0013180-00Medicaid
FLCH531ZMedicare PIN
FLP01047282Medicare PIN