Provider Demographics
NPI:1679771893
Name:FORD, HALEY J (PA)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:J
Last Name:FORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:J
Other - Last Name:HENKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1625 DORWART DR STE B
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:NE
Mailing Address - Zip Code:69162-2505
Mailing Address - Country:US
Mailing Address - Phone:308-254-4852
Mailing Address - Fax:308-254-7252
Practice Address - Street 1:1625 DORWART DR STE B
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NE
Practice Address - Zip Code:69162-2505
Practice Address - Country:US
Practice Address - Phone:308-254-4852
Practice Address - Fax:308-254-7252
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1008363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1078172OtherNATIONAL COMMISSION OF CE