1346650298 NPI number — MR. JUDSON AUSTIN HAYNES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346650298 NPI number — MR. JUDSON AUSTIN HAYNES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAYNES
Provider First Name:
JUDSON
Provider Middle Name:
AUSTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1346650298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3888 NW RANDALL WAY STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-7847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-698-5883
Provider Business Mailing Address Fax Number:
360-809-6002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 KALA POINT DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT TOWNSEND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98368-9530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-698-5883
Provider Business Practice Location Address Fax Number:
360-809-6002
Provider Enumeration Date:
04/30/2014

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: 101YA0400X , with the licence number:  CP60211997 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: LH60531241 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2254794 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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