MEDICARE: HALEY CRITES PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	5601006912	MI

General Provider Information

NPI Number	:	1477976363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY CRITES PA-C

Provider Business Mailing Address
First Line	:	52375 N MAIN ST
Second Line	:	BOX 89
City	:	MATTAWAN
State	:	MI
Zip	:	49071-9332
Country	:	US
Telephone Number	:	269-668-3348
Fax Number	:	269-668-7702

Provider Business Practice Location Address
First Line	:	52375 N MAIN ST
Second Line	:	BOX 89
City	:	MATTAWAN
State	:	MI
Zip	:	49071-9332
Country	:	US
Telephone Number	:	269-668-3348
Fax Number	:	269-668-7702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2014
Last Update Date	:	03/05/2015

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Directions to “ HALEY CRITES PA-C” Practice Location

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