Healthcare Provider Details

I. General information

NPI: 1699288027
Provider Name (Legal Business Name): HALEY MORGAN ROBERSON ISSICHOPOULOS MSM, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 PORTOLA RD
PORTOLA VALLEY CA
94028-7207
US

IV. Provider business mailing address

620 MOUNTAIN HOME RD
WOODSIDE CA
94062-2516
US

V. Phone/Fax

Practice location:
  • Phone: 650-494-1000
  • Fax:
Mailing address:
  • Phone: 650-799-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number54940
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number54950
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number54940
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: