Provider Demographics
NPI:1942009196
Name:HAZELWOOD, MICHAEL QUENTIN (MSA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:QUENTIN
Last Name:HAZELWOOD
Suffix:
Gender:M
Credentials:MSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 SLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:SUTHERLIN
Mailing Address - State:VA
Mailing Address - Zip Code:24594-3121
Mailing Address - Country:US
Mailing Address - Phone:434-334-4211
Mailing Address - Fax:
Practice Address - Street 1:2204 WILBORN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1645
Practice Address - Country:US
Practice Address - Phone:434-517-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000590246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant