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General NPI Number Information
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NPI Number | 1154610731
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Entity Type | Organization
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Legal Business Name | MARY HAFER, MD
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Dates
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Enumeration Date | 04/04/2011
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Last Update Date | 04/04/2011
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Provider Practice Location Address
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Address Line | 2971 E COPPER POINT DR SUITE # 125
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City | MERIDIAN
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State | ID
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Zip | 83642-5101
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Country | US
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Telephone | 208-893-5383
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Fax | 208-893-5386
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Provider Business Mailing Address
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Address Line | 2971 E COPPER POINT DR SUITE # 125
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City | MERIDIAN
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State | ID
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Zip | 83642-5101
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Country | US
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Telephone | 208-893-5383
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Fax | 208-893-5386
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MICHELE JANEE LOUCAO
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Credential |
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Telephone | 208-893-5383
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA-895
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | M-7753
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License Number State | ID
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