Provider Demographics
NPI:1255907580
Name:HETRICK, ALEXANDER DANIEL (DO)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:DANIEL
Last Name:HETRICK
Suffix:
Gender:M
Credentials:DO
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 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:6 13TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5315
Practice Address - Country:US
Practice Address - Phone:406-883-5680
Practice Address - Fax:406-883-8910
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-132526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine