Provider Demographics
NPI:1942517131
Name:HATHAWAY, MARK ALLEN
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
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 1:833 SW 11TH AVE
Mailing Address - Street 2:SUITE 428
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:833 SW 11TH AVE
Practice Address - Street 2:SUITE 428
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2125
Practice Address - Country:US
Practice Address - Phone:503-228-1510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3831943347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle