Provider Demographics
NPI:1912426362
Name:HAYNES, ROBERT D JR (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:HAYNES
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:DARRELL
Other - Last Name:HAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3474
Mailing Address - Fax:239-343-2968
Practice Address - Street 1:13685 DOCTORS WAY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4337
Practice Address - Country:US
Practice Address - Phone:239-343-1612
Practice Address - Fax:239-343-4229
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022322200Medicaid