Basic Information
| Provider Information | |||||||||
| NPI: | 1316962111 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATHAWAY | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | ROSANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981224201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063291760 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 509 OLIVE WAY | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981011720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068604691 | ||||||||
| FaxNumber: | 2063291261 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD00046586 | WA | Y | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | MD00046586 | WA | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X | MD00046586 | WA | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1007587 | 05 | WA | MEDICAID | MD00046586 | 01 | WA | MEDICAL LICENSE NUMBER | OTHER |