Provider Demographics
NPI:1265947741
Name:HEBA, MARK (LPN)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HEBA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:HEBA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1680 WALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4914
Mailing Address - Country:US
Mailing Address - Phone:716-894-7777
Mailing Address - Fax:716-896-0738
Practice Address - Street 1:1680 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4914
Practice Address - Country:US
Practice Address - Phone:716-894-7777
Practice Address - Fax:716-896-0738
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210891163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1841384906Medicaid