Basic Information
| Provider Information | |||||||||
| NPI: | 1477529519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALEY | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | M. | ||||||||
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| OtherLastName: | HALEY | ||||||||
| OtherFirstName: | JACK | ||||||||
| OtherMiddleName: | M. | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 173817 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802178643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 N. BOISE AVE. | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805387282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706354071 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 07/31/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 735 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA.000735 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01331724 | 01 | CO | RAILROAD MEDICARE | OTHER | 55625029 | 05 | CO | MEDICAID |