Healthcare Provider Details

I. General information

NPI: 1225003551
Provider Name (Legal Business Name): SHIRLEY LYNN HAYNES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD SUITE 600
SAINT LOUIS MO
63141-6345
US

IV. Provider business mailing address

91-1001 HOKUIMO ST
KAPOLEI HI
96707-3078
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-3982
  • Fax: 877-685-9866
Mailing address:
  • Phone: 808-398-2209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00545
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: