Healthcare Provider Details

I. General information

NPI: 1699882175
Provider Name (Legal Business Name): ELIZABETH A HEINTZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAINT ANTHONYS WAY SUITE 205
ALTON IL
62002-4569
US

IV. Provider business mailing address

PO BOX 9040
ALTON IL
62002-9040
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-8019
  • Fax: 618-463-5004
Mailing address:
  • Phone: 618-462-0499
  • Fax: 618-462-1150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085002576
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: