Provider Demographics
NPI:1578533071
Name:HATHAWAY, MILDRED (CRNA)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2506
Mailing Address - Country:US
Mailing Address - Phone:602-371-2964
Mailing Address - Fax:
Practice Address - Street 1:755 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2506
Practice Address - Country:US
Practice Address - Phone:602-371-2964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN045974367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ491829Medicaid
AZ491829Medicaid
AZP77524Medicare UPIN