Provider Demographics
NPI:1619618428
Name:HALL, HALEY (PA)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6131 164TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-4305
Mailing Address - Country:US
Mailing Address - Phone:941-779-5339
Mailing Address - Fax:
Practice Address - Street 1:6050 STATE ROAD 70 E UNIT A
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-9700
Practice Address - Country:US
Practice Address - Phone:941-907-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-05
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant