Provider Demographics
NPI:1629005749
Name:HATHAWAY, NICKOLINE M (MD)
Entity Type:Individual
Prefix:DR
First Name:NICKOLINE
Middle Name:M
Last Name:HATHAWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 PIONEER LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2563
Mailing Address - Country:US
Mailing Address - Phone:760-873-7111
Mailing Address - Fax:
Practice Address - Street 1:152 PIONEER LN
Practice Address - Street 2:SUITE C
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2563
Practice Address - Country:US
Practice Address - Phone:760-873-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G477050Medicaid
CA00G477050Medicare ID - Type Unspecified
CAA50785Medicare UPIN