1487711719 NPI number — MARY KAIA HALVERSON-DURALL PA-C

Table of content: MARY KAIA HALVERSON-DURALL PA-C (NPI 1487711719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487711719 NPI number — MARY KAIA HALVERSON-DURALL PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALVERSON-DURALL
Provider First Name:
MARY
Provider Middle Name:
KAIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALVERSON
Provider Other First Name:
MARY
Provider Other Middle Name:
KAIA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487711719
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1950 ASHFORD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLOVER
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54467-3050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-252-6999
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 FREMONT ST
Provider Second Line Business Practice Location Address:
UWSP HEALTH SERVICE
Provider Business Practice Location Address City Name:
STEVENS POINT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54481-3105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-346-4646
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  995-023 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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