Provider Demographics
NPI:1619484656
Name:HATHORN, CORNELIUS
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:HATHORN
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 1:16208 WINDHAVEN PKWY
Mailing Address - Street 2:APT 1307
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16208 WINDHAVEN PKWY
Practice Address - Street 2:APT 1307
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056
Practice Address - Country:US
Practice Address - Phone:254-251-8086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)