Provider Demographics
NPI:1023309796
Name:HAVEMAN, STACEY RENEE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:RENEE
Last Name:HAVEMAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:RENEE
Other - Last Name:COWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:55 W TIETAN ST
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4445
Mailing Address - Country:US
Mailing Address - Phone:509-525-3720
Mailing Address - Fax:509-522-1592
Practice Address - Street 1:55 W TIETAN ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-4445
Practice Address - Country:US
Practice Address - Phone:509-525-3720
Practice Address - Fax:509-522-1592
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60389054363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03465758Medicaid
NYJ400045859Medicare PIN