Healthcare Provider Details

I. General information

NPI: 1578152427
Provider Name (Legal Business Name): LISA MARIE HATHAWAY PA-C, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2819 GREAT NORTHERN LOOP STE 100
MISSOULA MT
59808-1750
US

IV. Provider business mailing address

2819 GREAT NORTHERN LOOP STE 100
MISSOULA MT
59808-1750
US

V. Phone/Fax

Practice location:
  • Phone: 406-282-3495
  • Fax:
Mailing address:
  • Phone: 406-327-3350
  • Fax: 406-327-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-94043
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1176977
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86048867
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: