Provider Demographics
NPI:1306956669
Name:HATHAWAY, CAROL L (MD, FACS, PS)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:MD, FACS, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 N HOUK RD
Mailing Address - Street 2:STE B
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1043
Mailing Address - Country:US
Mailing Address - Phone:509-921-9938
Mailing Address - Fax:509-921-5877
Practice Address - Street 1:1415 N HOUK RD
Practice Address - Street 2:STE B
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1043
Practice Address - Country:US
Practice Address - Phone:509-921-9938
Practice Address - Fax:509-921-5877
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF89377Medicare UPIN