Provider Demographics
NPI:1528391901
Name:HAYNES, SERGIO EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:EDWARD
Last Name:HAYNES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 SW WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-8338
Mailing Address - Country:US
Mailing Address - Phone:817-916-5180
Mailing Address - Fax:817-916-5199
Practice Address - Street 1:2730 SW WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-8338
Practice Address - Country:US
Practice Address - Phone:817-916-5180
Practice Address - Fax:817-916-5199
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06243363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX842N29OtherBCBS
TX211072801Medicaid
TX211072802OtherCSHCN
TX211072803Medicaid
TX211072802OtherCSHCN
TX211072801Medicaid