Provider Demographics
NPI:1659602811
Name:HEGEWALD, MICHAEL DOUGLAS
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DOUGLAS
Last Name:HEGEWALD
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 1:4204 NE 44TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661
Mailing Address - Country:US
Mailing Address - Phone:360-921-8377
Mailing Address - Fax:
Practice Address - Street 1:2004 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3327
Practice Address - Country:US
Practice Address - Phone:360-993-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60117362174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist