Basic Information
| Provider Information | |||||||||
| NPI: | 1720093677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | TREVOR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 649 HARKLE RD STE E | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059898200 | ||||||||
| FaxNumber: | 5059898131 | ||||||||
| Practice Location | |||||||||
| Address1: | 649 HARKLE RD STE E | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875054765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059898200 | ||||||||
| FaxNumber: | 5059898131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 83-212 | NM | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 27110 | 05 | NM | MEDICAID | PROVP14050 | 01 | NM | MOLINA SALUD | OTHER | NM000390 | 01 | NM | BCBS | OTHER | 201004174 | 01 | NM | PHP | OTHER |