Basic Information
| Provider Information | |||||||||
| NPI: | 1659353738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAVENS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 912 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | LITTLEFORK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566539357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182786634 | ||||||||
| FaxNumber: | 2182786637 | ||||||||
| Practice Location | |||||||||
| Address1: | 912 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | LITTLEFORK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 566539357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182786634 | ||||||||
| FaxNumber: | 2182786637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 04/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8194 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 24789 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0020-14029 | 05 | NV | MEDICAID | 2014029 | 05 | NV | MEDICAID |