Provider Demographics
NPI:1538418678
Name:HAVER, LAURA GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:GRACE
Last Name:HAVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9230
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:8725 N WICKHAM RD STE 200
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2240
Practice Address - Country:US
Practice Address - Phone:321-434-9230
Practice Address - Fax:321-434-9269
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106534363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGV589YOtherMEDICARE
FL010403100Medicaid