Provider Demographics
NPI:1407546898
Name:VERHAEGHE, MARY ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:VERHAEGHE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:LIZZY
Other - Middle Name:
Other - Last Name:VERHAEGHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:621 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:ID
Mailing Address - Zip Code:83313-5093
Mailing Address - Country:US
Mailing Address - Phone:208-725-3145
Mailing Address - Fax:208-725-3146
Practice Address - Street 1:621 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:ID
Practice Address - Zip Code:83313-5093
Practice Address - Country:US
Practice Address - Phone:208-725-3145
Practice Address - Fax:208-725-3146
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4871142363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical