Provider Demographics
NPI:1992797625
Name:HAYDEN, GARY D (PA-C)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:D
Last Name:HAYDEN
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 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4693
Mailing Address - Country:US
Mailing Address - Phone:217-238-6055
Mailing Address - Fax:
Practice Address - Street 1:1215 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-1252
Practice Address - Country:US
Practice Address - Phone:217-774-4305
Practice Address - Fax:217-774-4306
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001274363AM0700X
IL085-001274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371444997OtherTIN
IL371444997OtherTIN
ILK32704Medicare PIN