Provider Demographics
NPI:1124791066
Name:HEATON, KALIN THOMAS
Entity type:Individual
Prefix:
First Name:KALIN
Middle Name:THOMAS
Last Name:HEATON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18001 HIGHLAND PARK RD APT 208
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-5002
Mailing Address - Country:US
Mailing Address - Phone:801-822-6317
Mailing Address - Fax:
Practice Address - Street 1:13401 N WESTERN AVE STE 301
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-1411
Practice Address - Country:US
Practice Address - Phone:405-218-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant