Provider Demographics
NPI:1730141771
Name:HAAK, BRIAN DOUGLAS (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:HAAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740209
Mailing Address - Street 2:DEPT 40038
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0209
Mailing Address - Country:US
Mailing Address - Phone:941-360-1566
Mailing Address - Fax:941-358-9818
Practice Address - Street 1:9140 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1233
Practice Address - Country:US
Practice Address - Phone:662-280-8222
Practice Address - Fax:662-280-5541
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAPRN A810134367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
R34701Medicare UPIN
MS430002082Medicare PIN