Provider Demographics
NPI:1356016182
Name:HEINLEN, WILLIAM DEREK (PA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DEREK
Last Name:HEINLEN
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14430 US HIGHWAY 1 STE 101
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3289
Mailing Address - Country:US
Mailing Address - Phone:772-581-8003
Mailing Address - Fax:772-581-8005
Practice Address - Street 1:14430 US HIGHWAY 1 STE 101
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3289
Practice Address - Country:US
Practice Address - Phone:772-581-8003
Practice Address - Fax:772-581-8005
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9115153363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120201000Medicaid