Healthcare Provider Details

I. General information

NPI: 1790709871
Provider Name (Legal Business Name): NEIL CULLEN HEFFERNAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 EASTEND BLVD
WILKES-BARRE PA
18711
US

IV. Provider business mailing address

30 FARMHOUSE RD
MOUNTAIN TOP PA
18707-1725
US

V. Phone/Fax

Practice location:
  • Phone: 570-824-3521
  • Fax:
Mailing address:
  • Phone: 570-474-6249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA001791L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: