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General NPI Number Information
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NPI Number | 1487066296
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Entity Type | Organization
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Legal Business Name | ALFRED W. HATHORN JR., M.D. APMC
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Dates
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Enumeration Date | 05/28/2014
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Last Update Date | 05/28/2014
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Provider Practice Location Address
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Address Line | 2120 BERT KOUN LOOP SUITE # L
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City | SHREVEPORT
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State | LA
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Zip | 71118-3351
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Country | US
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Telephone | 318-686-8197
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Fax | 318-688-5962
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Provider Business Mailing Address
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Address Line | 2120 BERT KOUN LOOP SUITE # L
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City | SHREVEPORT
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State | LA
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Zip | 71118-3351
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Country | US
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Telephone | 318-686-8197
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Fax | 318-688-5962
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | RUTH A HATHORN
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Credential |
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Telephone | 318-686-8197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | AP06110
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 011400
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License Number State | LA
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