Healthcare Provider Details

I. General information

NPI: 1629253141
Provider Name (Legal Business Name): WALTER A HAINES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 MAIN ST
WATERVILLE ME
04901-6623
US

IV. Provider business mailing address

150 DRESDEN AVE
GARDINER ME
04345-2615
US

V. Phone/Fax

Practice location:
  • Phone: 207-872-1715
  • Fax: 207-872-1725
Mailing address:
  • Phone: 207-621-9337
  • Fax: 207-621-3609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA001114
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: