Healthcare Provider Details

I. General information

NPI: 1417338880
Provider Name (Legal Business Name): JAMES HEAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N MAIN ST
EAGAR AZ
85925-9813
US

IV. Provider business mailing address

1600 PROVIDENCE DR ATTN: TRACI MITCHELL - ADMN
WACO TX
76707-2261
US

V. Phone/Fax

Practice location:
  • Phone: 928-333-5333
  • Fax: 928-333-5100
Mailing address:
  • Phone: 254-313-4200
  • Fax: 254-313-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10054653
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number54657
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: