Basic Information
| Provider Information | |||||||||
| NPI: | 1831194307 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUETTMAN | ||||||||
| FirstName: | PACKY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 WEST KIMBERLY ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 WEST KIMBERLY ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 03132 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2167544 | 05 | IA | MEDICAID | 67701 | 01 | IOWA HEALTH SOLUTIONS | OTHER | 4796890008 | 01 | DMERC | OTHER | 066152 | 01 | HEALTH ALLIANCE | OTHER | 30409 | 01 | WELLMARK BC/BS | OTHER | IA01D2 | 01 | JOHN DEERE HEALTH PLAN | OTHER |