Provider Demographics
NPI:1326611419
Name:CLISSOLD, HAILEY SMITH (PA-C)
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:SMITH
Last Name:CLISSOLD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CAPCOM AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3219
Mailing Address - Country:US
Mailing Address - Phone:919-436-4124
Mailing Address - Fax:
Practice Address - Street 1:110 CAPCOM AVE STE 103
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6531
Practice Address - Country:US
Practice Address - Phone:919-436-4124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-13113363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program