Provider Demographics
NPI:1376563395
Name:HATFIELD, COREY Q (PA-C)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:Q
Last Name:HATFIELD
Suffix:
Gender:M
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 1:1019 PACIFIC AVE STE 300
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-4488
Mailing Address - Country:US
Mailing Address - Phone:253-722-1540
Mailing Address - Fax:253-597-4556
Practice Address - Street 1:1202 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3926
Practice Address - Country:US
Practice Address - Phone:253-441-4742
Practice Address - Fax:253-442-8790
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004371363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8356859Medicaid