Provider Demographics
NPI:1083806111
Name:TOTAL FAMILY HEALTH, PC
Entity Type:Organization
Organization Name:TOTAL FAMILY HEALTH, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:307-382-2080
Mailing Address - Street 1:2620 COMMERCIAL WAY
Mailing Address - Street 2:SUITE 051
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4755
Mailing Address - Country:US
Mailing Address - Phone:307-382-2080
Mailing Address - Fax:307-382-5099
Practice Address - Street 1:2620 COMMERCIAL WAY
Practice Address - Street 2:SUITE 051
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4755
Practice Address - Country:US
Practice Address - Phone:307-382-2080
Practice Address - Fax:307-382-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY17189.0261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118483100Medicaid
312190OtherBLUE CROSS BLUE SHIELD
P96969Medicare UPIN
312190OtherBLUE CROSS BLUE SHIELD