Provider Demographics
NPI:1093110603
Name:HAYNIE, TIFFANY L (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:HAYNIE
Suffix:
Gender:F
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 1:1684 E BOSTON ST
Mailing Address - Street 2:STE 102
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6220
Mailing Address - Country:US
Mailing Address - Phone:480-964-0080
Mailing Address - Fax:480-644-0931
Practice Address - Street 1:1684 E BOSTON ST STE 102
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-6220
Practice Address - Country:US
Practice Address - Phone:480-448-2411
Practice Address - Fax:480-476-8718
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5801363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5801OtherSTATE LICENSE NUMBER