Provider Demographics
NPI:1013090554
Name:HEITZ, LAURA J (NP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:HEITZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 COMMERCIAL WAY
Mailing Address - Street 2:SUITE 051
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4755
Mailing Address - Country:US
Mailing Address - Phone:307-382-2080
Mailing Address - Fax:307-382-5099
Practice Address - Street 1:2620 COMMERCIAL WAY
Practice Address - Street 2:SUITE 051
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4755
Practice Address - Country:US
Practice Address - Phone:307-382-2080
Practice Address - Fax:307-382-5099
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY17189.0261363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
312190OtherBLUE CROSS BLUE SHIELD
WY260064367OtherTAX ID
WY17189.0261OtherSTATE NURSING LICENSE
WY118483100Medicaid
312190OtherBLUE CROSS BLUE SHIELD
WYW9752Medicare PIN