1740256965 NPI number — MS. MINDY SUSAN HAENN PA-C

Table of content: MS. MINDY SUSAN HAENN PA-C (NPI 1740256965)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740256965 NPI number — MS. MINDY SUSAN HAENN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAENN
Provider First Name:
MINDY
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740256965
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 COOPER PLZ
Provider Second Line Business Mailing Address:
SUITE 403
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-342-3113
Provider Business Mailing Address Fax Number:
856-541-5379

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 COOPER PLZ
Provider Second Line Business Practice Location Address:
SUITE 411
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08103-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-342-3113
Provider Business Practice Location Address Fax Number:
856-968-8388
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  C5-0000363 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207T00000X , with the licence number: C5-0000363 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 25MP00161700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Q41476 . This is a "BLUE SHIELD OF DE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2935112 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0001001202 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2120316000 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2120316000 . This is a "BLUE SHIELD PC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2120316000 . This is a "KEYSTONE" identifier . This identifiers is of the category "OTHER".




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