Provider Demographics
NPI:1487842761
Name:HAVERLAND, KENNETH A (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:HAVERLAND
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST STE AA115
Mailing Address - Street 2:BOX # 356310
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:206-543-3093
Mailing Address - Fax:206-543-0325
Practice Address - Street 1:1959 NE PACIFIC ST STE AA115
Practice Address - Street 2:BOX # 356310
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-543-3093
Practice Address - Fax:206-543-0325
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2008-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005309363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8869235Medicare PIN