Provider Demographics
NPI:1790736908
Name:HAINES, JEFFREY (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HAINES
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 1:8243 BLACK HAW CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3200
Mailing Address - Country:US
Mailing Address - Phone:301-631-1831
Mailing Address - Fax:
Practice Address - Street 1:400 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4506
Practice Address - Country:US
Practice Address - Phone:240-566-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003197363A00000X
VA0110002154363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00272236OtherRAILROAD MEDICARE
VAQ55901Medicare UPIN
VAP00272236OtherRAILROAD MEDICARE
VA018310B00Medicare ID - Type Unspecified
MDH733S625Medicare PIN
MDOB00Medicare PIN