Provider Demographics
NPI:1073619938
Name:HAYNES, DEBORAH WALCK (PA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:WALCK
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14450 NEWTGATE RD.
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:AL
Mailing Address - Zip Code:23113
Mailing Address - Country:US
Mailing Address - Phone:804-379-2631
Mailing Address - Fax:
Practice Address - Street 1:MCGUIRE VA MEDICAL CENTER
Practice Address - Street 2:1201 BROAD ROCK BLVD. (151)
Practice Address - City:RICHMOND
Practice Address - State:AL
Practice Address - Zip Code:23249
Practice Address - Country:US
Practice Address - Phone:804-675-6136
Practice Address - Fax:804-675-6536
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840188363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical