Provider Demographics
NPI:1235128166
Name:HAYNES, WILLAIM J (AT)
Entity Type:Individual
Prefix:MR
First Name:WILLAIM
Middle Name:J
Last Name:HAYNES
Suffix:
Gender:M
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 ROSSTON RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71857-2533
Mailing Address - Country:US
Mailing Address - Phone:870-887-2622
Mailing Address - Fax:
Practice Address - Street 1:501 N HERVEY ST
Practice Address - Street 2:ATTN: MICHAEL A. SMITH
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-3435
Practice Address - Country:US
Practice Address - Phone:870-777-6798
Practice Address - Fax:870-777-6880
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT1292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARAT129OtherATHLETIC TRAINER LIC.