Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 49636-020 | WI |
N | 207QG0300X | Family Doctor - Geriatric Medicine | 49636-020 | WI |
NPI | 1083721286 |
---|---|
Provider Name | Charles J Heyka |
First Address | Green Bay, WI 54305-1866 |
Second Address | Oconto, WI 54153-2004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2006 |
Last Update Date | 20/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A78001 | (02) |