Healthcare Provider Details

I. General information

NPI: 1750818019
Provider Name (Legal Business Name): JOHN CASEY HEFFERNAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2017
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 CHASE AVE
WALLA WALLA WA
99362-2924
US

IV. Provider business mailing address

380 CHASE AVE
WALLA WALLA WA
99362-2924
US

V. Phone/Fax

Practice location:
  • Phone: 509-897-5836
  • Fax: 509-897-5743
Mailing address:
  • Phone: 509-897-5836
  • Fax: 509-897-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOP61434635
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: