Provider Demographics
NPI:1790701498
Name:HAAS, JACK W (PA-C)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:W
Last Name:HAAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:202 PROSPECT DR
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-1943
Mailing Address - Country:US
Mailing Address - Phone:406-345-3306
Mailing Address - Fax:406-345-3358
Practice Address - Street 1:202 PROSPECT DR
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-1943
Practice Address - Country:US
Practice Address - Phone:406-345-3306
Practice Address - Fax:406-345-3358
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant