Provider Demographics
NPI:1982790176
Name:HEISEY, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HEISEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-1564
Mailing Address - Country:US
Mailing Address - Phone:509-865-5600
Mailing Address - Fax:509-865-5783
Practice Address - Street 1:510 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1564
Practice Address - Country:US
Practice Address - Phone:509-865-5600
Practice Address - Fax:509-865-5783
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA63561OtherL & I
22899OtherGROUP HEALTH
WA8138935OtherCHPW
WA8138935Medicaid
911019392OtherCOMMERCIAL
WAHE0007OtherREGENCE
22899OtherGROUP HEALTH
AB16276Medicare ID - Type UnspecifiedRR MEDICARE
WA8138935Medicaid