Healthcare Provider Details

I. General information

NPI: 1386400745
Provider Name (Legal Business Name): CHARLES R HEATON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LITCHFIELD ST FL 6
TORRINGTON CT
06790-6679
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-496-6825
  • Fax:
Mailing address:
  • Phone: 603-777-1000
  • Fax: 603-777-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2174
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number7766
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2174
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: