Healthcare Provider Details

I. General information

NPI: 1679599864
Provider Name (Legal Business Name): HAROLD J HERBST PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MAIN STREET
HAWLEY MN
56549
US

IV. Provider business mailing address

PO BOX 746 1412 MAIN STREET
HAWLEY MN
56549-0746
US

V. Phone/Fax

Practice location:
  • Phone: 218-483-3564
  • Fax: 218-483-3567
Mailing address:
  • Phone: 218-483-3564
  • Fax: 218-483-3567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9077
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: