Healthcare Provider Details

I. General information

NPI: 1518984525
Provider Name (Legal Business Name): AMY HENEGHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 EL CAMINO REAL
PALO ALTO CA
94301-2302
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 650-853-2992
  • Fax:
Mailing address:
  • Phone: 650-853-2992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberG87921
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: