Healthcare Provider Details

I. General information

NPI: 1053734681
Provider Name (Legal Business Name): EMILY HATCH HOLLAWAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9716 RIVERSIDE PKWY STE 100
TULSA OK
74137-7450
US

IV. Provider business mailing address

9126 S BRADEN PL
TULSA OK
74137-4030
US

V. Phone/Fax

Practice location:
  • Phone: 918-299-4333
  • Fax:
Mailing address:
  • Phone: 918-521-7202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2316
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: