Provider Demographics
NPI:1386183994
Name:HASELEY, KEITH BRANDON (PA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BRANDON
Last Name:HASELEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6113 BAER RD
Mailing Address - Street 2:
Mailing Address - City:SANBORN
Mailing Address - State:NY
Mailing Address - Zip Code:14132-9264
Mailing Address - Country:US
Mailing Address - Phone:716-425-7215
Mailing Address - Fax:
Practice Address - Street 1:2099 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228
Practice Address - Country:US
Practice Address - Phone:716-710-8072
Practice Address - Fax:716-710-8082
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020599363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant