Healthcare Provider Details

I. General information

NPI: 1912426362
Provider Name (Legal Business Name): ROBERT D HAYNES JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ROBERT DARRELL HAYNES

II. Dates (important events)

Enumeration Date: 09/18/2017
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13685 DOCTORS WAY STE 100
FORT MYERS FL
33912-4337
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1612
  • Fax: 239-343-4229
Mailing address:
  • Phone: 239-343-3474
  • Fax: 239-343-2968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110678
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: