Basic Information
| Provider Information | |||||||||
| NPI: | 1518389170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 PINE ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786338682 | ||||||||
| FaxNumber: | 4786338698 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 PINE ST | ||||||||
| Address2: | STE 500 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786338682 | ||||||||
| FaxNumber: | 4786338698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2014 | ||||||||
| LastUpdateDate: | 01/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 007073 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 007073 | 01 | GA | GA LIC NUMBER | OTHER |