Provider Demographics
NPI:1518389170
Name:HAYNES, JONATHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:HAYNES
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 1:840 PINE ST
Mailing Address - Street 2:STE 500
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2100
Mailing Address - Country:US
Mailing Address - Phone:478-633-8682
Mailing Address - Fax:478-633-8698
Practice Address - Street 1:840 PINE ST
Practice Address - Street 2:STE 500
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2100
Practice Address - Country:US
Practice Address - Phone:478-633-8682
Practice Address - Fax:478-633-8698
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA007073OtherGA LIC NUMBER