Provider Demographics
NPI:1679599864
Name:HERBST, HAROLD J (PA-C)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:J
Last Name:HERBST
Suffix:
Gender:M
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:PO BOX 746
Mailing Address - Street 2:1412 MAIN STREET
Mailing Address - City:HAWLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56549-0746
Mailing Address - Country:US
Mailing Address - Phone:218-483-3564
Mailing Address - Fax:218-483-3567
Practice Address - Street 1:1412 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HAWLEY
Practice Address - State:MN
Practice Address - Zip Code:56549
Practice Address - Country:US
Practice Address - Phone:218-483-3564
Practice Address - Fax:218-483-3567
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9077363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1001271OtherPREFERREDONE
20642OtherSIOUX VALLEY
61A01HEOtherMN BC
ND71103Medicaid
HP25754OtherHEALTHPARTNERS
23576OtherND BC
0111645OtherMEDICA
MN701826600Medicaid
970003849OtherND RR
970003854OtherMN RR
944702OtherAMERICAS PPO
NDN4664OtherND MEDICARE
61A01HEOtherMN BC
970000235Medicare ID - Type Unspecified