Provider Demographics
NPI:1386668234
Name:HAIRE, RICHARD EUGENE (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:EUGENE
Last Name:HAIRE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-579-8363
Mailing Address - Fax:910-579-8306
Practice Address - Street 1:75 EMERSON BAY RD STE 102
Practice Address - Street 2:
Practice Address - City:CAROLINA SHORES
Practice Address - State:NC
Practice Address - Zip Code:28467-2498
Practice Address - Country:US
Practice Address - Phone:910-579-8363
Practice Address - Fax:910-579-8306
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00194363A00000X
SC2160363A00000X
NC0010-08101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006893Medicaid
11650341OtherCAQH
RIS66033Medicare UPIN
RI7006893Medicare ID - Type UnspecifiedMEDICARE