Provider Demographics
NPI:1669563763
Name:HATHAWAY, SCOTT A (DO)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 N BARTLETT ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2127
Mailing Address - Country:US
Mailing Address - Phone:715-526-2111
Mailing Address - Fax:715-526-9174
Practice Address - Street 1:309 N BARTLETT ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2127
Practice Address - Country:US
Practice Address - Phone:715-526-2111
Practice Address - Fax:715-526-9174
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36307207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30064500Medicaid
WI007400454Medicare ID - Type Unspecified
WI30064500Medicaid