MEDICARE: GARY HEASTON PA-C

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	363A00000X	Physician Assistant	324779-1206	UT

General Provider Information

NPI Number	:	1083672992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY HEASTON PA-C

Provider Business Mailing Address
First Line	:	JENSEN OCCUPATIONAL MEDICAL CENTER
Second Line	:	7238 6TH ST. BLDG 249
City	:	HILL AIR FORCE BASE
State	:	UT
Zip	:	84056-5213
Country	:	US
Telephone Number	:	801-777-1157
Fax Number	:

Provider Business Practice Location Address
First Line	:	7238 6TH ST
Second Line	:	JENSEN OCCUPATIONAL MEDICINE CENTER, BLDG. 249
City	:	HILL AIR FORCE BASE
State	:	UT
Zip	:	84056-5213
Country	:	US
Telephone Number	:	801-777-1157
Fax Number	:

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

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	05/07/2025

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