Healthcare Provider Details

I. General information

NPI: 1356016182
Provider Name (Legal Business Name): WILLIAM DEREK HEINLEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S HARBOR CITY BLVD STE 430
MELBOURNE FL
32901-5591
US

IV. Provider business mailing address

14430 US HIGHWAY 1 STE 101
SEBASTIAN FL
32958-3289
US

V. Phone/Fax

Practice location:
  • Phone: 321-344-8746
  • Fax: 321-339-1932
Mailing address:
  • Phone: 772-581-8003
  • Fax: 772-581-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9115153
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: