Basic Information
| Provider Information | |||||||||
| NPI: | 1073627956 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | LANA | ||||||||
| MiddleName: | MICHELLE OLIVER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | OLIVER | ||||||||
| OtherFirstName: | LANA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
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| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1618 STONES EDGE LOOP | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284058449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109871306 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1717 SHIPYARD BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284038023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107945355 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 12/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001000360 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.