Provider Demographics
NPI:1639160369
Name:HAYNES, TANA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:TANA
Middle Name:MARIE
Last Name:HAYNES
Suffix:
Gender:F
Credentials:MD
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 869
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-0869
Mailing Address - Country:US
Mailing Address - Phone:503-691-0169
Mailing Address - Fax:503-699-9237
Practice Address - Street 1:19260 SW 65TH AVE STE 270
Practice Address - Street 2:SUITE B2
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-5705
Practice Address - Country:US
Practice Address - Phone:503-699-0764
Practice Address - Fax:503-329-1851
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24660207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029123Medicaid
OR029123Medicaid
ORR117230Medicare ID - Type Unspecified