Provider Demographics
NPI:1487711719
Name:HALVERSON-DURALL, MARY KAIA (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KAIA
Last Name:HALVERSON-DURALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAIA
Other - Last Name:HALVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1950 ASHFORD DR
Mailing Address - Street 2:
Mailing Address - City:PLOVER
Mailing Address - State:WI
Mailing Address - Zip Code:54467-3050
Mailing Address - Country:US
Mailing Address - Phone:715-252-6999
Mailing Address - Fax:
Practice Address - Street 1:910 FREMONT ST
Practice Address - Street 2:UWSP HEALTH SERVICE
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-3105
Practice Address - Country:US
Practice Address - Phone:715-346-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI995-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant