Healthcare Provider Details

I. General information

NPI: 1700955499
Provider Name (Legal Business Name): JOSEPH HERON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 GRANDVIEW AVE
WATERBURY CT
06708-2505
US

IV. Provider business mailing address

39 KELLEY ST
BRISTOL CT
06010-5704
US

V. Phone/Fax

Practice location:
  • Phone: 203-757-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number003492
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: