Provider Demographics
NPI:1629759469
Name:HAVERSTUHL, MITCHELL (DNAP)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:HAVERSTUHL
Suffix:
Gender:M
Credentials:DNAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 DOTTERERS RUN
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5820
Mailing Address - Country:US
Mailing Address - Phone:219-393-0469
Mailing Address - Fax:
Practice Address - Street 1:9263 MEDICAL PLAZA DR STE E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-7112
Practice Address - Country:US
Practice Address - Phone:843-572-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-25
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN239047163W00000X
SC148290367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse