Provider Demographics
NPI:1588816722
Name:HAUBRICH, GREGORY J (PAC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:HAUBRICH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2745
Mailing Address - Country:US
Mailing Address - Phone:719-584-4306
Mailing Address - Fax:719-595-7886
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-584-4306
Practice Address - Fax:719-595-7886
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104817363A00000X
COPA.0003032363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAU340XMedicare PIN
FLAU340YMedicare PIN
P00656271Medicare PIN
FLAU340ZMedicare PIN