Healthcare Provider Details

I. General information

NPI: 1083061501
Provider Name (Legal Business Name): KEVAN J. HAACK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BROADWAY FL 7
SEATTLE WA
98122-5330
US

IV. Provider business mailing address

601 BROADWAY FL 7
SEATTLE WA
98122-5330
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-2600
  • Fax: 206-622-1644
Mailing address:
  • Phone: 206-386-2600
  • Fax: 206-622-1644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60815264
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: