Healthcare Provider Details

I. General information

NPI: 1003048620
Provider Name (Legal Business Name): TINA LISA HECK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA LISA PRAVONGVIENGKHAM

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S MAIN ST STE 105
TEMPLETON CA
93465-9348
US

IV. Provider business mailing address

212 S MAIN ST STE 105
TEMPLETON CA
93465-9348
US

V. Phone/Fax

Practice location:
  • Phone: 805-788-8129
  • Fax: 805-244-0445
Mailing address:
  • Phone: 805-788-8129
  • Fax: 805-244-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: