Basic Information
| Provider Information | |||||||||
| NPI: | 1124093232 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATTAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 PIERCE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122262600 | ||||||||
| FaxNumber: | 7122262605 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH SIOUX CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687763144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024124220 | ||||||||
| FaxNumber: | 7124941365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 18829 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3929745 | 05 | IA | MEDICAID | 10025302400 | 05 | NE | MEDICAID |