Provider Demographics
NPI:1639697709
Name:MOAK, HALEY BROOKE (PA-C)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:BROOKE
Last Name:MOAK
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 1:911 SW 21ST AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1565
Mailing Address - Country:US
Mailing Address - Phone:541-519-2923
Mailing Address - Fax:
Practice Address - Street 1:10803 SE CHERRY BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3107
Practice Address - Country:US
Practice Address - Phone:503-261-7200
Practice Address - Fax:503-261-7226
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty