Provider Demographics
NPI:1902913445
Name:HALEY, CHRISTINE (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:HALEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK STREET,
Mailing Address - Street 2:CB-2041
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510
Mailing Address - Country:US
Mailing Address - Phone:203-688-4748
Mailing Address - Fax:203-688-4740
Practice Address - Street 1:20 YORK STREET,
Practice Address - Street 2:CB-2041
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:203-688-4740
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00192363A00000X
CT000192363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000686Medicare ID - Type Unspecified
CTS81941Medicare UPIN