Basic Information
| Provider Information | |||||||||
| NPI: | 1790064343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAWKINS | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALTERS | ||||||||
| OtherFirstName: | CARRIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291161245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033954497 | ||||||||
| FaxNumber: | 8033952237 | ||||||||
| Practice Location | |||||||||
| Address1: | 1175 COOK RD STE 215 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291188201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083953837 | ||||||||
| FaxNumber: | 8035365122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2011 | ||||||||
| LastUpdateDate: | 08/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | APPLIED FOR | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1667 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | GP4401 | 05 | SC | MEDICAID |