Provider Demographics
NPI:1699288027
Name:ISSICHOPOULOS, HALEY MORGAN ROBERSON (MSM, PA-C)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:MORGAN ROBERSON
Last Name:ISSICHOPOULOS
Suffix:
Gender:F
Credentials:MSM, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 MOUNTAIN HOME RD
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2516
Mailing Address - Country:US
Mailing Address - Phone:650-799-0330
Mailing Address - Fax:
Practice Address - Street 1:844 PORTOLA RD
Practice Address - Street 2:
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7207
Practice Address - Country:US
Practice Address - Phone:650-494-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54940207YX0901X, 363AM0700X
CA54950363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical