Provider Demographics
NPI:1962987198
Name:HATHAWAY, LILLIAN JOY (PA-C)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:JOY
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 TRIPPS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:RI
Mailing Address - Zip Code:02822-2937
Mailing Address - Country:US
Mailing Address - Phone:401-339-8854
Mailing Address - Fax:
Practice Address - Street 1:1798 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2918
Practice Address - Country:US
Practice Address - Phone:909-865-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55913363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant