Provider Demographics
NPI:1912965278
Name:HETTINGA, ROSE A (APN)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:A
Last Name:HETTINGA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CORPORATE CIR
Mailing Address - Street 2:190
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7724
Mailing Address - Country:US
Mailing Address - Phone:702-932-8547
Mailing Address - Fax:702-932-8587
Practice Address - Street 1:600 WHITNEY RANCH DR
Practice Address - Street 2:B6
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-2611
Practice Address - Country:US
Practice Address - Phone:702-547-0088
Practice Address - Fax:702-434-1579
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV000582207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00367731OtherRAILROAD MEDICARE
NVP00367731OtherRAILROAD MEDICARE
S73753Medicare UPIN
100736Medicare ID - Type Unspecified