Provider Demographics
NPI:1417338880
Name:HEAP, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:HEAP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 PROVIDENCE DR
Mailing Address - Street 2:ATTN: TRACI MITCHELL - ADMN
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:606 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9813
Practice Address - Country:US
Practice Address - Phone:928-333-5333
Practice Address - Fax:928-333-5100
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10054653207Q00000X
AZ54657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ377055Medicaid