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NPI Code Detail

MEDICARE: MR. THEODORE DAVID HAYNES JR. CRNA

MEDICARE: MR. THEODORE DAVID HAYNES JR. CRNA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse Anesthetist549839TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
186602UOTHERTXBCBSTX

General Provider Information

NPI Number : 1144294158
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. THEODORE DAVID HAYNES JR. CRNA
Provider Business Mailing Address
First Line : 2959 S SHEPHERDS GLN
Second Line :
City : WICHITA FALLS
State : TX
Zip : 76308-5450
Country : US
Telephone Number : 940-691-1151
Fax Number :
Provider Business Practice Location Address
First Line : 1600 11TH ST
Second Line : DEPT. ANESTHESIA
City : WICHITA FALLS
State : TX
Zip : 76301-4300
Country : US
Telephone Number : 940-764-3390
Fax Number : 940-764-3391
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/15/2006
Last Update Date : 11/19/2007

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