MEDICARE: SHAWN ROBERT O'HAVER AG-ACNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	AP11115	AZ

General Provider Information

NPI Number	:	1922450493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAWN ROBERT O'HAVER AG-ACNP

Provider Business Mailing Address
First Line	:	84 ACOMA BLVD N STE 106
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6096
Country	:	US
Telephone Number	:	928-412-8808
Fax Number	:	928-412-8807

Provider Business Practice Location Address
First Line	:	84 ACOMA BLVD N STE 106
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6096
Country	:	US
Telephone Number	:	928-412-8808
Fax Number	:	928-412-8807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2016
Last Update Date	:	11/11/2021

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