Provider Demographics
NPI:1992765747
Name:HETTICH, THOMAS GLEN (PA-C)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:GLEN
Last Name:HETTICH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3534 DIAZ ST
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2163
Mailing Address - Country:US
Mailing Address - Phone:727-644-2597
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE
Practice Address - Street 2:ATTN: SOCCENT CLINIC
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-827-9213
Practice Address - Fax:813-827-1319
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1049243OtherNCCPA CERTIFICATION NUM
NYDD4595Medicare UPIN