Healthcare Provider Details

I. General information

NPI: 1912924358
Provider Name (Legal Business Name): CRAIG ALLAN HAVERMANN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 10TH STREET SE
CEDAR RAPIDS IA
52403-2404
US

IV. Provider business mailing address

PO BOX 3178
CEDAR RAPIDS IA
52406-3178
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-1506
  • Fax: 319-558-4062
Mailing address:
  • Phone: 319-398-1583
  • Fax: 319-399-2085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00156
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001279
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00156
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerIOWA LICENSE, ATC
# 2
Identifier960644
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerNATA MEMBER #
# 3
Identifier089702522
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerNATABOC #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: