Basic Information
| Provider Information | |||||||||
| NPI: | 1982821922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAFFNER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 NW LOVEJOY ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972105101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032266321 | ||||||||
| FaxNumber: | 5032273422 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 NW LOVEJOY ST | ||||||||
| Address2: | SUITE 315 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972105101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032266321 | ||||||||
| FaxNumber: | 5032273422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 09/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1618 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA158963 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA60291947 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1982821922 | 05 | WA | MEDICAID | 500645833 | 05 | OR | MEDICAID |