Provider Demographics
NPI:1639172901
Name:KLEIN, PAUL EDWARD
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:EDWARD
Last Name:KLEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:EDWARD
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:3832 BEAR DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-4375
Mailing Address - Country:US
Mailing Address - Phone:218-790-3962
Mailing Address - Fax:
Practice Address - Street 1:1799 KIOWA AVE STE 104
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-505-1030
Practice Address - Fax:928-453-0461
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN188709163W00000X
MNR1337222363L00000X
AZAP7448363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN150132100Medicaid
MN1639172901Medicaid
ND19795Medicaid
AZ980120Medicaid
MN500007530Medicare PIN
MN150132100Medicaid