Provider Demographics
NPI:1841487840
Name:HALE, NICHOLAS A (PA)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:A
Last Name:HALE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4531
Mailing Address - Country:US
Mailing Address - Phone:208-478-7422
Mailing Address - Fax:
Practice Address - Street 1:495 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4531
Practice Address - Country:US
Practice Address - Phone:208-478-7422
Practice Address - Fax:208-478-1515
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-686363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA-686OtherSTATE LICENSE NUMBER