Provider Demographics
NPI:1154610731
Name:MARY HAFER, MD
Entity type:Organization
Organization Name:MARY HAFER, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:JANEE
Authorized Official - Last Name:LOUCAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-893-5383
Mailing Address - Street 1:2971 E COPPER POINT DR
Mailing Address - Street 2:SUITE # 125
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5101
Mailing Address - Country:US
Mailing Address - Phone:208-893-5383
Mailing Address - Fax:208-893-5386
Practice Address - Street 1:2971 E COPPER POINT DR
Practice Address - Street 2:SUITE # 125
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5101
Practice Address - Country:US
Practice Address - Phone:208-893-5383
Practice Address - Fax:208-893-5386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7753174400000X
IDPA-895363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM-7753OtherIDAHO STATE MEDICAL LICENSE