Provider Demographics
NPI:1902578131
Name:SHAULL, HAILEY GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:GRACE
Last Name:SHAULL
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 S WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1441
Mailing Address - Country:US
Mailing Address - Phone:608-931-7557
Mailing Address - Fax:
Practice Address - Street 1:7430 WENTWORTH AVE
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4133
Practice Address - Country:US
Practice Address - Phone:612-488-0040
Practice Address - Fax:833-973-4055
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MN13878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant