Provider Demographics
NPI:1083672992
Name:HEASTON, GARY (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:HEASTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 S 600 E
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-2723
Mailing Address - Country:US
Mailing Address - Phone:435-723-7077
Mailing Address - Fax:
Practice Address - Street 1:7238 6TH ST
Practice Address - Street 2:JENSEN OCCUPATIONAL MEDICINE CENTER, BLDG. 249
Practice Address - City:HILL AIR FORCE BASE
Practice Address - State:UT
Practice Address - Zip Code:84056-5213
Practice Address - Country:US
Practice Address - Phone:801-777-1157
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324779-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant