Provider Demographics
NPI:1407306434
Name:HAVEN MEDICAL, LLC
Entity Type:Organization
Organization Name:HAVEN MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C, MSHS
Authorized Official - Phone:907-263-2200
Mailing Address - Street 1:3340 PROVIDENCE DR
Mailing Address - Street 2:STE 466
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4691
Mailing Address - Country:US
Mailing Address - Phone:907-263-2200
Mailing Address - Fax:
Practice Address - Street 1:3340 PROVIDENCE DR
Practice Address - Street 2:STE 466
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4691
Practice Address - Country:US
Practice Address - Phone:907-263-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty