Provider Demographics
NPI:1558475699
Name:HALEY, MARK MASON (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MASON
Last Name:HALEY
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:ONE GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93407-0210
Mailing Address - Country:US
Mailing Address - Phone:805-756-1211
Mailing Address - Fax:
Practice Address - Street 1:ONE GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93407-0210
Practice Address - Country:US
Practice Address - Phone:805-756-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA173940Medicare ID - Type Unspecified
CA0PA173941Medicare PIN
CAQ47362Medicare UPIN