Basic Information
| Provider Information | |||||||||
| NPI: | 1578152427 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATHAWAY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C, RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063273350 | ||||||||
| FaxNumber: | 4063273355 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W SPRUCE ST STE J | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063273350 | ||||||||
| FaxNumber: | 4063273355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2021 | ||||||||
| LastUpdateDate: | 11/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1176977 | NV | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | MED-PAC-LIC-94043 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.