Provider Demographics
NPI:1487259537
Name:HAYNES, JOHNATHAN M (DNAP)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:M
Last Name:HAYNES
Suffix:
Gender:M
Credentials:DNAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N RACE ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3454
Mailing Address - Country:US
Mailing Address - Phone:270-651-4444
Mailing Address - Fax:270-651-4892
Practice Address - Street 1:1301 N RACE ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3454
Practice Address - Country:US
Practice Address - Phone:270-651-4444
Practice Address - Fax:270-651-4892
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28898367500000X
KY3015871367500000X
TN211520163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine