Provider Demographics
NPI:1073023248
Name:HEIDE, MITCHELL ROBERT (PA)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ROBERT
Last Name:HEIDE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:240 W JUNIPER AVE UNIT 1057
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-3980
Mailing Address - Country:US
Mailing Address - Phone:480-789-2399
Mailing Address - Fax:
Practice Address - Street 1:1455 W CHANDLER BLVD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6177
Practice Address - Country:US
Practice Address - Phone:480-917-9208
Practice Address - Fax:480-814-7443
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ6883363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant