Provider Demographics
NPI:1063439511
Name:DE HAVEN, KURT DOUGLAS (CRNP)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:DOUGLAS
Last Name:DE HAVEN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E NORTH AVE STE 363
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-4756
Mailing Address - Country:US
Mailing Address - Phone:412-359-6137
Mailing Address - Fax:412-359-4334
Practice Address - Street 1:320 E NORTH AVE STE 363
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15212-4756
Practice Address - Country:US
Practice Address - Phone:412-359-6137
Practice Address - Fax:412-359-4334
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008316363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029987870001Medicaid
Q22535Medicare UPIN
PA1029987870001Medicaid