Basic Information
| Provider Information | |||||||||
| NPI: | 1598755258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301C US ROUTE 1 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 2073968632 | ||||||||
| Practice Location | |||||||||
| Address1: | 335 BRIGHTON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076628600 | ||||||||
| FaxNumber: | 2076628668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 08/14/2012 | ||||||||
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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 | 363AS0400X | PA742 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 010416156 | 01 | CIGNA | OTHER | 041374 | 01 | ANTHEM | OTHER | 100294000 | 01 | USPS | OTHER | 010416156 | 01 | TRAVELERS/CORE/MEDNET | OTHER | 261270099 | 05 | ME | MEDICAID | 970026451 | 01 | RR MEDICARE | OTHER | 0378600001 | 01 | DMERC | OTHER | 1044480 | 01 | AETNA | OTHER |