Provider Demographics
NPI:1790709871
Name:HEFFERNAN, NEIL CULLEN (PA)
Entity Type:Individual
Prefix:MR
First Name:NEIL
Middle Name:CULLEN
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:30 FARMHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1725
Mailing Address - Country:US
Mailing Address - Phone:570-474-6249
Mailing Address - Fax:
Practice Address - Street 1:1111 EASTEND BLVD
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001791L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAVAD000Medicare UPIN