Basic Information
Provider Information | |||||||||
NPI: | 1861447245 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HESTON | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | F | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 JACOBS GULCH RD | ||||||||
Address2: |   | ||||||||
City: | KELLOGG | ||||||||
State: | ID | ||||||||
PostalCode: | 838372023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087831267 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 25 JACOBS GULCH RD | ||||||||
Address2: |   | ||||||||
City: | KELLOGG | ||||||||
State: | ID | ||||||||
PostalCode: | 838372023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087831267 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 02/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | M6643 | ID | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine |   | 207UN0901X | MD00032355 | WA | N |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207Q00000X | M6643 | ID | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00305935 | 01 | WA | RAILROAD MEDICARE | OTHER | 423898078 | 01 | WA | GROUP HEALTH COOPERATIVE | OTHER | 0197912 | 01 | WA | L&I (REGULAR) | OTHER | 3976HE | 01 | WA | REGENCE BLUESHIELD | OTHER | 804135600 | 05 | ID |   | MEDICAID | 8192759 | 05 | WA |   | MEDICAID | 8906064 | 01 | WA | L&I (CRIME VICTIM) | OTHER |