Provider Demographics
NPI:1891884268
Name:HEIDRICK, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HEIDRICK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-5898
Mailing Address - Fax:
Practice Address - Street 1:1175 MOUNT HOOD AVENUE
Practice Address - Street 2:
Practice Address - City:WOODBURN
Practice Address - State:OR
Practice Address - Zip Code:97071
Practice Address - Country:US
Practice Address - Phone:503-982-2000
Practice Address - Fax:503-982-0660
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00369363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067463016OtherREGENCE
911019392OtherCOMMERCIAL
M066501OtherPACIFIC SOURCE
911019392OtherCOMMERCIAL
R109784Medicare ID - Type Unspecified
M066501OtherPACIFIC SOURCE