Healthcare Provider Details

I. General information

NPI: 1740256965
Provider Name (Legal Business Name): MINDY SUSAN HAENN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ SUITE 411
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

3 COOPER PLZ SUITE 403
CAMDEN NJ
08103-1438
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-3113
  • Fax: 856-968-8388
Mailing address:
  • Phone: 856-342-3113
  • Fax: 856-541-5379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC5-0000363
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberC5-0000363
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00161700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: