Individual
LAURA GRACE HAVER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
8725 N WICKHAM RD STE 200, MELBOURNE, FL 32940-2240
(321) 434-9230
(321) 434-9269
Mailing address
3300 S FISKE BLVD, ROCKLEDGE, FL 32955-4306
(321) 434-9230
(321) 951-7408
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA9106534
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010403100
—
FL
01
—
GV589Y
MEDICARE
FL
Enumeration date
09/05/2012
Last updated
07/02/2019
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