Provider Demographics
NPI:1073627956
Name:HAYNES, LANA MICHELLE OLIVER (PAC)
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:MICHELLE OLIVER
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LANA
Other - Middle Name:MICHELLE
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1618 STONES EDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-8449
Mailing Address - Country:US
Mailing Address - Phone:910-987-1306
Mailing Address - Fax:
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8023
Practice Address - Country:US
Practice Address - Phone:910-794-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q68696Medicare UPIN