Provider Demographics
NPI:1063524718
Name:HEISCHMIDT, PAUL A (CRNA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:HEISCHMIDT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 WEST PORT PLAZA
Mailing Address - Street 2:STE 270
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146
Mailing Address - Country:US
Mailing Address - Phone:314-453-0600
Mailing Address - Fax:314-453-0083
Practice Address - Street 1:3 PROFESSIONAL DR
Practice Address - Street 2:STE B
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-465-7177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL91080Medicare ID - Type Unspecified