Provider Demographics
NPI:1144294158
Name:HAYNES, THEODORE DAVID JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:DAVID
Last Name:HAYNES
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2959 S SHEPHERDS GLN
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-5450
Mailing Address - Country:US
Mailing Address - Phone:940-691-1151
Mailing Address - Fax:
Practice Address - Street 1:1600 11TH ST
Practice Address - Street 2:DEPT. ANESTHESIA
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-4300
Practice Address - Country:US
Practice Address - Phone:940-764-3390
Practice Address - Fax:940-764-3391
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX549839367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86602UOtherBCBSTX
TX8G6995Medicare PIN