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NPI Code Detail

MEDICARE: JEREMY SCOTT HATAWAY FNP-BC

MEDICARE: JEREMY SCOTT HATAWAY FNP-BC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LF0000XFamily Nurse Practitioner5004212NC
2363LF0000XFamily Nurse Practitioner670631TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1670631OTHERTXNP LICENSE

General Provider Information

NPI Number : 1528203155
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEREMY SCOTT HATAWAY FNP-BC
Provider Business Mailing Address
First Line : 4560 LAKE RIDGE PKWY STE 110
Second Line :
City : GRAND PRAIRIE
State : TX
Zip : 75052-1707
Country : US
Telephone Number : 972-522-7778
Fax Number : 972-522-7779
Provider Business Practice Location Address
First Line : 4560 LAKE RIDGE PKWY STE 110
Second Line :
City : GRAND PRAIRIE
State : TX
Zip : 75052-1707
Country : US
Telephone Number : 972-522-7778
Fax Number : 972-522-7779
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/11/2008
Last Update Date : 10/06/2021

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