Basic Information
| Provider Information | |||||||||
| NPI: | 1285200923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEYREND | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | DARWIN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 57950 LEAVENWORTH ST | ||||||||
| Address2: | |||||||||
| City: | MCCONNELL AFB | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672213505 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 57950 LEAVENWORTH ST | ||||||||
| Address2: | |||||||||
| City: | MCCONNELL AFB | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672213505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3167596300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2021 | ||||||||
| LastUpdateDate: | 11/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 02006970A | IN | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.