Healthcare Provider Details

I. General information

NPI: 1154610731
Provider Name (Legal Business Name): MARY HAFER, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2971 E COPPER POINT DR SUITE # 125
MERIDIAN ID
83642-5101
US

IV. Provider business mailing address

2971 E COPPER POINT DR SUITE # 125
MERIDIAN ID
83642-5101
US

V. Phone/Fax

Practice location:
  • Phone: 208-893-5383
  • Fax: 208-893-5386
Mailing address:
  • Phone: 208-893-5383
  • Fax: 208-893-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM-7753
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-895
License Number StateID

VIII. Authorized Official

Name: MICHELE JANEE LOUCAO
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-893-5383