Healthcare Provider Details

I. General information

NPI: 1093110603
Provider Name (Legal Business Name): TIFFANY L HAYNIE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1684 E BOSTON ST STE 102
GILBERT AZ
85295-6220
US

IV. Provider business mailing address

1684 E BOSTON ST STE 102
GILBERT AZ
85295-6220
US

V. Phone/Fax

Practice location:
  • Phone: 480-448-2411
  • Fax: 480-476-8718
Mailing address:
  • Phone: 480-964-0080
  • Fax: 480-644-0931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5801
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: