Basic Information
Provider Information | |||||||||
NPI: | 1174626089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEANEY | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA/C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 61 HOME ST | ||||||||
Address2: |   | ||||||||
City: | BERLIN | ||||||||
State: | NH | ||||||||
PostalCode: | 03570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037529252 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 186 MEDICAL VILLAGE DR | ||||||||
Address2: |   | ||||||||
City: | NEWPORT | ||||||||
State: | VT | ||||||||
PostalCode: | 058558537 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8023343520 | ||||||||
FaxNumber: | 8023343512 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2006 | ||||||||
LastUpdateDate: | 07/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 055-0030775 | VT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | AP102301 | 01 | VT | MEDICARE | OTHER | 9000297 | 05 | VT |   | MEDICAID |