Provider Demographics
NPI:1689602625
Name:HAYNES, GARY V (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:V
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 1:639 GRAT STRASSE RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158-9582
Mailing Address - Country:US
Mailing Address - Phone:734-649-1481
Mailing Address - Fax:
Practice Address - Street 1:639 GRAT STRASSE RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48158-9582
Practice Address - Country:US
Practice Address - Phone:734-646-0087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003265363AM0700X
RIPA00447363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001995OtherLICENSE
MIP02023Medicare UPIN