Provider Demographics
NPI:1427503721
Name:HAYES, STEPHANIE
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:HAYES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:082-302-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6140 W CURTISIAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0107
Practice Address - Country:US
Practice Address - Phone:208-302-0000
Practice Address - Fax:208-302-0055
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4883363AS0400X
IDPA-1408363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AOtherN/A