Healthcare Provider Details

I. General information

NPI: 1366418113
Provider Name (Legal Business Name): LARRY TRAVIS HEAP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 11/21/2007
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

PO BOX 1610
SPRINGERVILLE AZ
85938-1610
US

V. Phone/Fax

Practice location:
  • Phone: 928-333-5333
  • Fax: 928-333-5100
Mailing address:
  • Phone: 928-333-5333
  • Fax: 928-333-5100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3048
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: