Provider Demographics
NPI:1730235383
Name:HALEY, KEVIN DAVID (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAVID
Last Name:HALEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 ALTON PKWY
Mailing Address - Street 2:SUITE 5-A-300
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3717
Mailing Address - Country:US
Mailing Address - Phone:949-654-4444
Mailing Address - Fax:
Practice Address - Street 1:5405 ALTON PKWY
Practice Address - Street 2:SUITE 5-A-300
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3717
Practice Address - Country:US
Practice Address - Phone:949-654-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12297Medicaid