Healthcare Provider Details

I. General information

NPI: 1548911175
Provider Name (Legal Business Name): ANDREW JACOB HEGLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COLLEGE HL
CANTON MO
63435-1299
US

IV. Provider business mailing address

511 COLLEGE ST
CANTON MO
63435-1340
US

V. Phone/Fax

Practice location:
  • Phone: 563-468-9908
  • Fax:
Mailing address:
  • Phone: 563-468-9908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number651AH6753
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: