Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 0102206528 | VA |
Y | 207Q00000X | Family Doctor | 006017 | AZ |
N | 207Q00000X | Family Doctor | R1704 | AZ |
NPI | 1275761991 |
---|---|
Provider Name | Dr. Gregory Heller |
First Address | Glendale, AZ 85308-6500 |
Second Address | Glendale, AZ 85308-6500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2009 |
Last Update Date | 30/04/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
R1704 | TRAINING PERMIT (01) | AZ |