Basic Information
| Provider Information | |||||||||
| NPI: | 1083934343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MILES | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 75216 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282750216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367187080 | ||||||||
| FaxNumber: | 3367189622 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 BETHESDA CT | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271033019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362778800 | ||||||||
| FaxNumber: | 3362778850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2010 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-02327 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8101963 | 05 | NC | MEDICAID |