Provider Demographics
NPI:1487703518
Name:HAVERKAMP, KENNETH K (PA-C)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
Last Name:HAVERKAMP
Suffix:
Gender:M
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 1:11511 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-8578
Mailing Address - Country:US
Mailing Address - Phone:425-502-3000
Mailing Address - Fax:425-502-3589
Practice Address - Street 1:11511 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-8578
Practice Address - Country:US
Practice Address - Phone:425-502-3000
Practice Address - Fax:425-502-3589
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004778363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8445488Medicaid
WAG8856882Medicare PIN
WAG8872369Medicare PIN
WAG8856878Medicare PIN
WAG8856879Medicare PIN
WAQ55285Medicare UPIN
WAG8856880Medicare PIN
WAG8856881Medicare PIN