Provider Demographics
NPI:1750866620
Name:HEFNER, THOMAS W (NP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:HEFNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BONNIE
Mailing Address - State:IL
Mailing Address - Zip Code:62816-1002
Mailing Address - Country:US
Mailing Address - Phone:618-967-2666
Mailing Address - Fax:
Practice Address - Street 1:365 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BONNIE
Practice Address - State:IL
Practice Address - Zip Code:62816-1002
Practice Address - Country:US
Practice Address - Phone:618-967-2666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily