Organization
MARY HAFER, MD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHELE JANEE LOUCAO (OFFICE MANAGER)
(208) 893-5383
Entity
Organization
Contact information
Practice address
2971 E COPPER POINT DR, SUITE # 125, MERIDIAN, ID 83642-5101
(208) 893-5383
(208) 893-5386
Mailing address
2971 E COPPER POINT DR, SUITE # 125, MERIDIAN, ID 83642-5101
(208) 893-5383
(208) 893-5386
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
M-7753
ID
363AM0700X
Medical Physician Assistant
PA-895
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
M-7753
IDAHO STATE MEDICAL LICENSE
ID
Enumeration date
04/04/2011
Last updated
04/04/2011
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