Provider Demographics
NPI:1841646726
Name:HEAVENER, TRACE (DO)
Entity type:Individual
Prefix:
First Name:TRACE
Middle Name:
Last Name:HEAVENER
Suffix:
Gender:
Credentials:DO
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4595
Mailing Address - Fax:208-625-4596
Practice Address - Street 1:1919 LINCOLN WAY STE 415
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2527
Practice Address - Country:US
Practice Address - Phone:208-625-4595
Practice Address - Fax:208-625-4596
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDO-1809207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology