Healthcare Provider Details

I. General information

NPI: 1629958574
Provider Name (Legal Business Name): EMILY HATTEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 N PENNSYLVANIA AVE
WILKES BARRE PA
18701-3603
US

IV. Provider business mailing address

15 BAYBERRY DR
MAHWAH NJ
07430-1502
US

V. Phone/Fax

Practice location:
  • Phone: 570-491-0126
  • Fax:
Mailing address:
  • Phone: 201-419-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA067133
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: