Basic Information
| Provider Information | |||||||||
| NPI: | 1285689521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEINS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 150 | ||||||||
| Address2: | |||||||||
| City: | HOLLY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810470150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195370712 | ||||||||
| FaxNumber: | 7195376284 | ||||||||
| Practice Location | |||||||||
| Address1: | 11600 W 2ND PL | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195370712 | ||||||||
| FaxNumber: | 7195376284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 07/31/2012 | ||||||||
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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 | 367500000X | R046483 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 128409 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 33624551 | 05 | CO | MEDICAID |