Basic Information
| Provider Information | |||||||||
| NPI: | 1689288144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEINEN | ||||||||
| FirstName: | PHILLIP | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 308 | ||||||||
| Address2: | |||||||||
| City: | QUEEN CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851421806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807185400 | ||||||||
| FaxNumber: | 8776664624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 E BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852831527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807185400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2020 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | TEMP246634 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.