=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023749231
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BYRON JAWON HATHORN NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2022
-----------------------------------------------------
Last Update Date | 01/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3070 HEALTHY WAY
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35243-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-977-7216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3070 HEALTHY WAY
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35243-2331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-977-7216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-170721
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------