Healthcare Provider Details

I. General information

NPI: 1871088765
Provider Name (Legal Business Name): EVAN HATHAWAY DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 E GRANT ST STE 3
WOODSTOWN NJ
08098-1400
US

IV. Provider business mailing address

PO BOX 146
WOODSTOWN NJ
08098-0146
US

V. Phone/Fax

Practice location:
  • Phone: 856-769-4564
  • Fax: 856-769-4637
Mailing address:
  • Phone: 856-769-4564
  • Fax: 856-769-4637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01795800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: