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General NPI Number Information
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NPI Number | 1922884139
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Entity Type | Individual
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Provider Name | ALYSSA HEITKAMP PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 09/04/2023
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Last Update Date | 11/11/2024
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Provider Practice Location Address
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Address Line | 220 S VAN BUREN ST
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City | ENID
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State | OK
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Zip | 73703-5812
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Country | US
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Telephone | 580-234-9355
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Fax |
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Provider Business Mailing Address
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Address Line | 35149 BIRDIE LN
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City | AVON
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State | OH
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Zip | 44011-3307
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Country | US
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Telephone | 440-371-1966
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5442
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License Number State | OK
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