Provider Demographics
NPI:1104806959
Name:HAUGEN, KEITH ALLEN (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:HAUGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 W FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WA
Mailing Address - Zip Code:99111-9552
Mailing Address - Country:US
Mailing Address - Phone:509-397-4717
Mailing Address - Fax:
Practice Address - Street 1:1210 W FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-9552
Practice Address - Country:US
Practice Address - Phone:509-397-4717
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG62936Medicare UPIN
WAAB38823Medicare ID - Type Unspecified