Healthcare Provider Details

I. General information

NPI: 1538418678
Provider Name (Legal Business Name): LAURA GRACE HAVER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 N WICKHAM RD STE 200
MELBOURNE FL
32940-2240
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-9230
  • Fax: 321-434-9269
Mailing address:
  • Phone: 321-434-9230
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9106534
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: