Provider Demographics
NPI:1407884257
Name:DEHAAN, STEPHEN (PAC)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:DEHAAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 COBB ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2588
Mailing Address - Country:US
Mailing Address - Phone:231-876-6527
Mailing Address - Fax:231-876-6519
Practice Address - Street 1:555 E WILCOX AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-7512
Practice Address - Country:US
Practice Address - Phone:231-689-3268
Practice Address - Fax:231-689-1030
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001543363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S58255Medicare UPIN
N81620003Medicare ID - Type Unspecified