Provider Demographics
NPI:1730101841
Name:GAINOR, HALEY THAXTON (PA-C)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:THAXTON
Last Name:GAINOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:E
Other - Last Name:THAXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 CIRCLE 75 PKWY SE
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3035
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:770-953-6972
Practice Address - Street 1:1265 HIGHWAY 54 W
Practice Address - Street 2:SUITE 102
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4548
Practice Address - Country:US
Practice Address - Phone:771-460-1900
Practice Address - Fax:770-719-1214
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00888417OtherRR MEDICARE
GA026138165AMedicaid
GAP00888417OtherRR MEDICARE
GAQ70225Medicare UPIN