Provider Demographics
NPI:1598755258
Name:HAYNES, NATHAN B (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:B
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 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:335 BRIGHTON AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2363
Practice Address - Country:US
Practice Address - Phone:207-662-8600
Practice Address - Fax:207-662-8668
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA742363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
010416156OtherCIGNA
041374OtherANTHEM
100294000OtherUSPS
010416156OtherTRAVELERS/CORE/MEDNET
ME261270099Medicaid
970026451OtherRR MEDICARE
0378600001OtherDMERC
1044480OtherAETNA
ME261270099Medicaid
041374OtherANTHEM
1044480OtherAETNA
MEAP151503Medicare PIN
MEP01043974Medicare PIN