Provider Demographics
NPI:1619449477
Name:HEISER, MARK ALAN (HIS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:HEISER
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 MESQUITE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5674
Mailing Address - Country:US
Mailing Address - Phone:928-855-5252
Mailing Address - Fax:928-855-5283
Practice Address - Street 1:1930 MESQUITE AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5674
Practice Address - Country:US
Practice Address - Phone:928-855-5252
Practice Address - Fax:928-855-5283
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHADE9721237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist