Provider Demographics
NPI:1649780818
Name:HAYNES, MEGAN M (PA-C)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:HAYNES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W DIVERSEY PKWY APT 1305
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1563
Mailing Address - Country:US
Mailing Address - Phone:859-221-8352
Mailing Address - Fax:
Practice Address - Street 1:5145 N CALIFORNIA AVE STE M331M274
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:773-293-4171
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006296363A00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant