Provider Demographics
NPI:1174636989
Name:HAYNES, ROY G (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:G
Last Name:HAYNES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:R
Other - Middle Name:GARLAND
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:2200 JACOBSSEN DR STE B
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5516
Mailing Address - Country:US
Mailing Address - Phone:309-451-1123
Mailing Address - Fax:309-451-1212
Practice Address - Street 1:2200 JACOBSSEN DR STE B
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-5516
Practice Address - Country:US
Practice Address - Phone:309-451-1123
Practice Address - Fax:309-451-1212
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-217502163W00000X
IN28163503A367500000X
IL209-001422367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS06909Medicare UPIN