Provider Demographics
NPI:1588108526
Name:HAVEA REGAN, ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:HAVEA REGAN
Suffix:
Gender:
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 1:1530 E HAMMER LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-3149
Mailing Address - Country:US
Mailing Address - Phone:209-954-3200
Mailing Address - Fax:209-954-3250
Practice Address - Street 1:1530 E HAMMER LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-3149
Practice Address - Country:US
Practice Address - Phone:209-954-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-09
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR222280363A00000X
CAPA55528363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant