Provider Demographics
NPI:1326484130
Name:HATHAWAY, COURTNEY IVERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:IVERSON
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18320 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:KS
Mailing Address - Zip Code:66030-9157
Mailing Address - Country:US
Mailing Address - Phone:913-856-5577
Mailing Address - Fax:913-856-3907
Practice Address - Street 1:18320 S CENTER ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:KS
Practice Address - Zip Code:66030-9157
Practice Address - Country:US
Practice Address - Phone:913-856-5577
Practice Address - Fax:913-856-3907
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-39132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201138500AMedicaid
KS201138500AMedicaid