Provider Demographics
NPI:1457794083
Name:HASKELL, MICHAEL RAY (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAY
Last Name:HASKELL
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 1:120 EAST HOWARD AVENUE
Mailing Address - Street 2:TETON VALLEY HEALTH CARE
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5112
Mailing Address - Country:US
Mailing Address - Phone:208-354-6352
Mailing Address - Fax:208-354-3158
Practice Address - Street 1:120 EAST HOWARD AVENUE
Practice Address - Street 2:TETON VALLEY HEALTH CARE
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5112
Practice Address - Country:US
Practice Address - Phone:208-354-6302
Practice Address - Fax:208-354-3158
Is Sole Proprietor?:No
Enumeration Date:2013-04-13
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY576363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical