Healthcare Provider Details

I. General information

NPI: 1912624594
Provider Name (Legal Business Name): ANDREW C HEAVYRUNNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 S RUSSELL ST
MISSOULA MT
59801-3629
US

IV. Provider business mailing address

2100 STEPHENS AVE STE 105
MISSOULA MT
59801-6607
US

V. Phone/Fax

Practice location:
  • Phone: 406-829-9515
  • Fax:
Mailing address:
  • Phone: 406-829-9515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number58896
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: