Individual
MR. KYLE JACOB HAVERCROFT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1107 W IRONWOOD DR, COEUR D ALENE, ID 83814-2604
(208) 667-7459
(208) 667-2631
Mailing address
2003 KOOTENAI HEALTH WAY, COEUR D ALENE, ID 83814-6051
(208) 625-4000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
PA-1313
ID
363AM0700X
Medical Physician Assistant
PA-1313
ID
363AS0400X
Surgical Physician Assistant
Primary
PA-1313
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1083729438
LINKED TO OSSM ORGANIZATION
—
Enumeration date
01/25/2008
Last updated
10/20/2016
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