Provider Demographics
NPI:1902578925
Name:MORTIN, HALEY NICOLE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:HALEY
Middle Name:NICOLE
Last Name:MORTIN
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:5890 S SWEET GUM WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6968
Mailing Address - Country:US
Mailing Address - Phone:208-298-7443
Mailing Address - Fax:
Practice Address - Street 1:745 BUENA VISTA DR # 82520
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3431
Practice Address - Country:US
Practice Address - Phone:307-332-2941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant