Basic Information
| Provider Information | |||||||||
| NPI: | 1134521909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HADALLER | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960973474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308424121 | ||||||||
| FaxNumber: | 5308410913 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960973474 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308424121 | ||||||||
| FaxNumber: | 5308410913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60494109 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA171878 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA60906 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.