Basic Information
| Provider Information | |||||||||
| NPI: | 1710957360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAULK | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2860 CREEKSIDE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417798367 | ||||||||
| FaxNumber: | 5417797471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MD61224828 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD21164 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | USA242450 | 05 | CA | MEDICAID | 005591005 | 01 | OR | REGENCE BLUE CROSS | OTHER | 158918 | 05 | OR | MEDICAID |