Provider Demographics
NPI:1295348860
Name:ROBERTS-HALEY, MADISON MARIE (PA)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:MARIE
Last Name:ROBERTS-HALEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1327 W SUPERIOR ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-2742
Mailing Address - Country:US
Mailing Address - Phone:208-263-9757
Mailing Address - Fax:208-965-8128
Practice Address - Street 1:1113 E WESTVIEW CT
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218-1319
Practice Address - Country:US
Practice Address - Phone:208-263-9757
Practice Address - Fax:208-965-8128
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61222036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant