Basic Information
Provider Information | |||||||||
NPI: | 1982790176 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEISEY | ||||||||
FirstName: | KYLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 W 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | TOPPENISH | ||||||||
State: | WA | ||||||||
PostalCode: | 989481564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098655600 | ||||||||
FaxNumber: | 5098655783 | ||||||||
Practice Location | |||||||||
Address1: | 510 W 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | TOPPENISH | ||||||||
State: | WA | ||||||||
PostalCode: | 989481564 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098655600 | ||||||||
FaxNumber: | 5098655783 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 03/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00028899 | WA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 63561 | 01 | WA | L & I | OTHER | 22899 | 01 |   | GROUP HEALTH | OTHER | 8138935 | 01 | WA | CHPW | OTHER | 8138935 | 05 | WA |   | MEDICAID | 911019392 | 01 |   | COMMERCIAL | OTHER | HE0007 | 01 | WA | REGENCE | OTHER |