Provider Demographics
NPI:1811935000
Name:DE HAAN, JOEL DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:DAVID
Last Name:DE HAAN
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 1:150 10TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MILACA
Mailing Address - State:MN
Mailing Address - Zip Code:56353-1737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 10TH ST NW
Practice Address - Street 2:
Practice Address - City:MILACA
Practice Address - State:MN
Practice Address - Zip Code:56353-1737
Practice Address - Country:US
Practice Address - Phone:320-983-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP29391Medicare UPIN