Provider Demographics
NPI:1578152427
Name:HATHAWAY, LISA MARIE (PA-C, RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-3350
Mailing Address - Fax:406-327-3355
Practice Address - Street 1:601 W SPRUCE ST STE J
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4047
Practice Address - Country:US
Practice Address - Phone:406-327-3350
Practice Address - Fax:406-327-3355
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1176977363AM0700X
MTMED-PAC-LIC-94043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical