Provider Demographics
NPI:1982821922
Name:HAFFNER, MARK WESLEY (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WESLEY
Last Name:HAFFNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2222 NW LOVEJOY ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5101
Mailing Address - Country:US
Mailing Address - Phone:503-226-6321
Mailing Address - Fax:503-227-3422
Practice Address - Street 1:2222 NW LOVEJOY ST
Practice Address - Street 2:SUITE 315
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5101
Practice Address - Country:US
Practice Address - Phone:503-226-6321
Practice Address - Fax:503-227-3422
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1618363AS0400X
ORPA158963363AS0400X
WAPA60291947363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1982821922Medicaid
OR500645833Medicaid
WA1982821922Medicaid
OR500645833Medicaid