Basic Information
| Provider Information | |||||||||
| NPI: | 1245531185 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASUKI | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13000 RIVERS BEND BLVD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238368632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045715000 | ||||||||
| FaxNumber: | 8045181314 | ||||||||
| Practice Location | |||||||||
| Address1: | 13034 RIVERS BEND RD | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238362564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045265888 | ||||||||
| FaxNumber: | 8045265401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2010 | ||||||||
| LastUpdateDate: | 02/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TL1593 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110003889 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1245531185 | 05 | VA | MEDICAID |