Healthcare Provider Details

I. General information

NPI: 1194418202
Provider Name (Legal Business Name): MR. STEPHAN HAAQUIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PINEWILD DR STE 2A
ROCHESTER NY
14606-4200
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-368-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax: 585-922-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number405724
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number221782
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number34381
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: