Healthcare Provider Details

I. General information

NPI: 1093420697
Provider Name (Legal Business Name): AYDAN LUKE HEAVNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 US 421 S
LILLINGTON NC
27546-6760
US

IV. Provider business mailing address

924 CLEAR CREEK CIR
LINCOLNTON NC
28092-8005
US

V. Phone/Fax

Practice location:
  • Phone: 910-893-1210
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001004740
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: