Provider Demographics
NPI:1194201947
Name:HEELAN, SCOTT RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RICHARD
Last Name:HEELAN
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 1:1942 FRANKLIN CT
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-6307
Mailing Address - Country:US
Mailing Address - Phone:847-714-3316
Mailing Address - Fax:
Practice Address - Street 1:1252 AMERICAN WAY
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3936
Practice Address - Country:US
Practice Address - Phone:224-424-4624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant