Provider Demographics
NPI:1144451139
Name:HAVEMAN, TAMMIE J
Entity type:Individual
Prefix:
First Name:TAMMIE
Middle Name:J
Last Name:HAVEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:J
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6025 LAKE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1712
Mailing Address - Country:US
Mailing Address - Phone:651-999-6800
Mailing Address - Fax:651-999-6830
Practice Address - Street 1:405 STAGELINE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7848
Practice Address - Country:US
Practice Address - Phone:715-531-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2819-23207P00000X
MN1306363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPENDINGMedicaid
MNPENDINGMedicare PIN