Provider Demographics
NPI:1619181203
Name:HATHAWAY, NOLAN
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 WARD RD
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-1951
Mailing Address - Country:US
Mailing Address - Phone:303-467-0500
Mailing Address - Fax:303-467-0502
Practice Address - Street 1:4855 WARD RD
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-1951
Practice Address - Country:US
Practice Address - Phone:303-467-0500
Practice Address - Fax:303-467-0502
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087648207R00000X, 207W00000X
CODR0054511207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine