=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063821700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER ANN NEAL PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2014
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3269 N STOCKTON HILL RD
-----------------------------------------------------
City | KINGMAN
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86409-3619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-757-2101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 WALTON WAY STE 192 PMB 514
-----------------------------------------------------
City | CEDAR PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78613-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-306-8730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA10358
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA2020-0044
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 2648
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 7212
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | MED-PAC-LIC-103548
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------