Provider Demographics
NPI:1619913100
Name:HAVERS, COURTENAY NICOLE (MD)
Entity Type:Individual
Prefix:
First Name:COURTENAY
Middle Name:NICOLE
Last Name:HAVERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11307 BRIDGEPORT WAY SW STE 220A
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3024
Mailing Address - Country:US
Mailing Address - Phone:253-985-2733
Mailing Address - Fax:360-744-6270
Practice Address - Street 1:11307 BRIDGEPORT WAY SW STE 220A
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3024
Practice Address - Country:US
Practice Address - Phone:253-985-2733
Practice Address - Fax:360-744-6270
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7405427OtherAETNA
P00023573OtherRAILROAD MEDICARE
WA1014702Medicaid
WA8359416Medicaid
8918BROtherREGENCE BLUESHIELD
WA169190OtherLABOR AND INDUSTRIES
WA169190OtherLABOR AND INDUSTRIES
WAGAB36811Medicare PIN
WAG8856728Medicare PIN
WAG8852219Medicare PIN
P00023573OtherRAILROAD MEDICARE
WAG8855432Medicare PIN
WAG8851423Medicare PIN
H81779Medicare UPIN