1225052566 NPI number — MS. CARRIE JO HEISINGER PAC

Table of content: MS. CARRIE JO HEISINGER PAC (NPI 1225052566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225052566 NPI number — MS. CARRIE JO HEISINGER PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEISINGER
Provider First Name:
CARRIE
Provider Middle Name:
JO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225052566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 N BEAVER ST
Provider Second Line Business Mailing Address:
PAYER CREDENTIALING
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-3118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-773-2559
Provider Business Mailing Address Fax Number:
928-213-6292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 SUNSET DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEDONA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86336-5406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-228-0030
Provider Business Practice Location Address Fax Number:
928-291-0175
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  3329 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 018949 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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