Provider Demographics
NPI:1740256965
Name:HAENN, MINDY SUSAN (PA-C)
Entity type:Individual
Prefix:MS
First Name:MINDY
Middle Name:SUSAN
Last Name:HAENN
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 1:3 COOPER PLZ
Mailing Address - Street 2:SUITE 403
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-342-3113
Mailing Address - Fax:856-541-5379
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:SUITE 411
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-342-3113
Practice Address - Fax:856-968-8388
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000363363AS0400X, 207T00000X
NJ25MP00161700363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q41476OtherBLUE SHIELD OF DE
2935112OtherAETNA
DE0001001202Medicaid
2120316000OtherAMERIHEALTH
2120316000OtherBLUE SHIELD PC
2120316000OtherKEYSTONE
Q41476OtherBLUE SHIELD OF DE
DE168597ZFABMedicare PIN