Basic Information
| Provider Information | |||||||||
| NPI: | 1497053433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEITMAN | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1770 HUDSON LOOP RD | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720348295 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2425 PRINCE ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720343701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013276665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2011 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 147446-30 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 147446-30 | 01 | WI | LICENSE | OTHER |