Healthcare Provider Details

I. General information

NPI: 1184387409
Provider Name (Legal Business Name): THOMAS PHILIP HEFFERNAN JR. PA-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2021
Last Update Date: 10/14/2021
Certification Date: 10/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 HUNTINGTON AVE
BOSTON MA
02115-5000
US

IV. Provider business mailing address

58 AUDUBON DR
WALPOLE MA
02081-2723
US

V. Phone/Fax

Practice location:
  • Phone: 617-373-3195
  • Fax:
Mailing address:
  • Phone: 508-660-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: