Healthcare Provider Details

I. General information

NPI: 1356032007
Provider Name (Legal Business Name): NICHOLAS ALEXANDER HEISLER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 09/28/2025
Certification Date: 09/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG AS4021, CANAL STREET MCAS NEW RIVER
JACKSONVILLE NC
28540
US

IV. Provider business mailing address

BLDG AS4021, CANAL STREET MCAS NEW RIVER
JACKSONVILLE NC
28540
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-2960
  • Fax:
Mailing address:
  • Phone: 910-450-2960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102208936
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: