Basic Information
| Provider Information | |||||||||
| NPI: | 1629045984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEITTER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ORVILLE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1990 N CALIFORNIA BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945967249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252255837 | ||||||||
| FaxNumber: | 9254822834 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E. WASHINGTON BLVD. | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074648888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2006 | ||||||||
| LastUpdateDate: | 03/12/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00751 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA12674 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.