MEDICARE: LAURA J HEITZ NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	17189.0261	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	312190	OTHER		BLUE CROSS BLUE SHIELD
2	260064367	OTHER	WY	TAX ID
3	17189.0261	OTHER	WY	STATE NURSING LICENSE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013090554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA J HEITZ NP

Provider Business Mailing Address
First Line	:	2620 COMMERCIAL WAY
Second Line	:	SUITE 051
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4755
Country	:	US
Telephone Number	:	307-382-2080
Fax Number	:	307-382-5099

Provider Business Practice Location Address
First Line	:	2620 COMMERCIAL WAY
Second Line	:	SUITE 051
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4755
Country	:	US
Telephone Number	:	307-382-2080
Fax Number	:	307-382-5099

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	01/25/2010

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