Basic Information
| Provider Information | |||||||||
| NPI: | 1487766036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HATTENBRUN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | LLOYD | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | FNP/ANP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HATTENBRUN | ||||||||
| OtherFirstName: | DAVID | ||||||||
| OtherMiddleName: | LLOYD | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | IV | ||||||||
| OtherCredential: | FNP-BC, ANP-BC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 222 ROUTE 299 | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125282524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456913627 | ||||||||
| FaxNumber: | 8456913641 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 ROUTE 299 | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125282524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456913627 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F333066 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | F333066 | 01 | NY | NYS NP LICENSE | OTHER |