Provider Demographics
NPI:1245253004
Name:HAYNES, GERALD A (PA)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:A
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:PO BOX 7422
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-0422
Mailing Address - Country:US
Mailing Address - Phone:757-599-4922
Mailing Address - Fax:757-599-4927
Practice Address - Street 1:3000 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-599-4922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY335363AM0700X
VA0110002566363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY20414OtherPIN
WY20414OtherPIN