=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427503721
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. STEPHANIE HAYES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2016
-----------------------------------------------------
Last Update Date | 07/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6140 W CURTISIAN AVE STE 200
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-0107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-302-0000
-----------------------------------------------------
Fax | 208-302-0055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 190930
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83719-0930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 82-302-5170
-----------------------------------------------------
Fax | 208-367-5180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 4883
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA-1408
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------