Basic Information
| Provider Information | |||||||||
| NPI: | 1396792156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAUTHAWAY | ||||||||
| FirstName: | MALCOLM | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 HOLLAND WAY FL 1 | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038332997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037787975 | ||||||||
| FaxNumber: | 6037787964 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 BORTHWICK AVE STE 308 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038017112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034315242 | ||||||||
| FaxNumber: | 6034334045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3076274 | 05 | NH | MEDICAID |