Provider Demographics
NPI:1386668234
Name:HAIRE, RICHARD EUGENE (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EUGENE
Last Name:HAIRE
Suffix:
Gender:M
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:PO BOX 2180
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-2180
Mailing Address - Country:US
Mailing Address - Phone:843-248-4414
Mailing Address - Fax:843-234-6990
Practice Address - Street 1:903 BELL ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4113
Practice Address - Country:US
Practice Address - Phone:843-248-4414
Practice Address - Fax:843-234-6990
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2160363A00000X
RIPA00194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006893Medicaid
11650341OtherCAQH
RIS66033Medicare UPIN
RI7006893Medicare ID - Type UnspecifiedMEDICARE