Basic Information
| Provider Information | |||||||||
| NPI: | 1124668231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALEY | ||||||||
| FirstName: | SUSANNA | ||||||||
| MiddleName: | LONG | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283035421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103089843 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2301 ROBESON ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104844100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2020 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-09668 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.