Healthcare Provider Details

I. General information

NPI: 1154344422
Provider Name (Legal Business Name): FIRST STATE FOOT & ANKLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4512 KIRKWOOD HIGHWAY SUITE 203
WILMINGTON DE
19808
US

IV. Provider business mailing address

4512 KIRKWOOD HIGHWAY SUITE 203
WILMINGTON DE
19808
US

V. Phone/Fax

Practice location:
  • Phone: 302-984-0257
  • Fax: 302-984-0258
Mailing address:
  • Phone: 302-984-0257
  • Fax: 302-984-0258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE1-0000143
License Number StateDE

VIII. Authorized Official

Name: HEATHER HOLVECK
Title or Position: OFFICE MANAGER
Credential:
Phone: 302-984-0257