Provider Demographics
NPI:1518075852
Name:DEHAVEN, ERIN (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:DEHAVEN
Suffix:
Gender:F
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 1:2840 S MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7960
Mailing Address - Country:US
Mailing Address - Phone:208-593-6393
Mailing Address - Fax:208-593-6402
Practice Address - Street 1:2840 S MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7960
Practice Address - Country:US
Practice Address - Phone:208-593-6393
Practice Address - Fax:208-593-6402
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807378700Medicaid
Q65789Medicare UPIN
ID1667563Medicare ID - Type Unspecified