Basic Information
| Provider Information | |||||||||
| NPI: | 1174593214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEINZEN | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2605 | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989072605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094544143 | ||||||||
| FaxNumber: | 5094543651 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989013020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094544143 | ||||||||
| FaxNumber: | 5094543651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 07/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00014515 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | G8877276 | 01 | WA | PTAN | OTHER | 8290603 | 05 | WA | MEDICAID |