Provider Demographics
NPI:1851540256
Name:HAFNER, MICHAEL WAYNE (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WAYNE
Last Name:HAFNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-6962
Mailing Address - Country:US
Mailing Address - Phone:405-707-0900
Mailing Address - Fax:405-707-3363
Practice Address - Street 1:511 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-6962
Practice Address - Country:US
Practice Address - Phone:405-707-0900
Practice Address - Fax:405-707-3363
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1771OtherSTATE LICENSE
OK200219760AMedicaid
OK401799Medicare PIN