Basic Information
Provider Information
NPI: 1003010893
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HATCHETTE
FirstName: ANDREA
MiddleName: S
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: MARVIN
OtherFirstName: ANDREA
OtherMiddleName: S
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential: MD
OtherLastNameType: 1
Mailing Information
Address1: 4333 N JOSEY LN STE 104
Address2:  
City: CARROLLTON
State: TX
PostalCode: 750104620
CountryCode: US
TelephoneNumber: 9723944500
FaxNumber: 9723948180
Practice Location
Address1: 4333 N JOSEY LN STE 104
Address2:  
City: CARROLLTON
State: TX
PostalCode: 750104620
CountryCode: US
TelephoneNumber: 9723944500
FaxNumber: 9723948180
Other Information
ProviderEnumerationDate: 06/13/2007
LastUpdateDate: 11/21/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208800000XN6479TXY Allopathic & Osteopathic PhysiciansUrology 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

ID Information
IDTypeStateIssuerDescription
21678010205TX MEDICAID
BP1-002724901 INSTITUTIONAL PERMITOTHER
21678010305TX MEDICAID
21678010105TX MEDICAID


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