Provider Demographics
NPI:1700063344
Name:HAVERCROFT, KYLE JACOB (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JACOB
Last Name:HAVERCROFT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:1107 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2604
Practice Address - Country:US
Practice Address - Phone:208-667-7459
Practice Address - Fax:208-667-2631
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1313363AM0700X, 363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1083729438OtherLINKED TO OSSM ORGANIZATION
1083729438OtherLINKED TO OSSM ORGANIZATION
ID20009691Medicare PIN
ID1374148Medicare PIN
ID20007950Medicare PIN