Provider Demographics
NPI:1013417104
Name:HASELIP, TROY ADAM (OWNER)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:ADAM
Last Name:HASELIP
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39349 RIVER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-8915
Mailing Address - Country:US
Mailing Address - Phone:541-971-5469
Mailing Address - Fax:
Practice Address - Street 1:39349 RIVER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-8915
Practice Address - Country:US
Practice Address - Phone:541-971-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9570911172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR26-3985015Medicaid