Provider Demographics
NPI:1275521437
Name:HATHAWAY, MATTHEW K (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:K
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 W HOUSTON ST STE B
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-3519
Mailing Address - Country:US
Mailing Address - Phone:918-259-1888
Mailing Address - Fax:918-251-3725
Practice Address - Street 1:512 SE WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-8231
Practice Address - Country:US
Practice Address - Phone:918-333-4343
Practice Address - Fax:918-333-4355
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200034560AMedicaid
OK248630602Medicare PIN