Provider Demographics
NPI:1164616108
Name:HAVENS, SARAH MCKENDRICK (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:MCKENDRICK
Last Name:HAVENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:MCKENDRICK
Other - Last Name:GROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3400
Mailing Address - Country:US
Mailing Address - Phone:586-261-2600
Mailing Address - Fax:586-261-2601
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3400
Practice Address - Country:US
Practice Address - Phone:586-261-2600
Practice Address - Fax:586-261-2601
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005040363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200E011770OtherBCBS GROUP NUMBER
MI5601005040OtherMICHIGAN LICENSE
MI20-5501357-0OtherBCBS PIN
MI20-5501357-0OtherBCBS PIN