Provider Demographics
NPI:1326089657
Name:HASKETT, MARY SUSAN (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:SUSAN
Last Name:HASKETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 286
Mailing Address - Street 2:
Mailing Address - City:GLEN HAVEN
Mailing Address - State:CO
Mailing Address - Zip Code:80532-0286
Mailing Address - Country:US
Mailing Address - Phone:970-586-5173
Mailing Address - Fax:
Practice Address - Street 1:1801 16TH ST
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-5154
Practice Address - Country:US
Practice Address - Phone:970-392-2352
Practice Address - Fax:970-350-6454
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN562646367500000X
COCRA-4559367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO45421331Medicaid
COCO307318Medicare PIN