Provider Demographics
NPI:1528203155
Name:HATAWAY, JEREMY SCOTT (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:HATAWAY
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 LAKE RIDGE PKWY STE 110
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-1707
Mailing Address - Country:US
Mailing Address - Phone:972-522-7778
Mailing Address - Fax:972-522-7779
Practice Address - Street 1:4560 LAKE RIDGE PKWY STE 110
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-1707
Practice Address - Country:US
Practice Address - Phone:972-522-7778
Practice Address - Fax:972-522-7779
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004212363LF0000X
TX670631363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX670631OtherNP LICENSE