Provider Demographics
NPI:1629253141
Name:HAINES, WALTER A (PA-C)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:A
Last Name:HAINES
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 1:150 DRESDEN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-2615
Mailing Address - Country:US
Mailing Address - Phone:207-621-9337
Mailing Address - Fax:207-621-3609
Practice Address - Street 1:149 MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6623
Practice Address - Country:US
Practice Address - Phone:207-872-1715
Practice Address - Fax:207-872-1725
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432854799Medicaid
ME432854799Medicaid