Provider Demographics
NPI:1821030891
Name:HEINL, RICHARD W (PA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:W
Last Name:HEINL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 EXECUTIVE PARK NW
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-2746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 EXECUTIVE PARK NW
Practice Address - Street 2:SUITE 5
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-2746
Practice Address - Country:US
Practice Address - Phone:423-479-9679
Practice Address - Fax:423-559-9046
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP08102Medicare UPIN