Provider Demographics
NPI:1316718737
Name:MOUTVIC, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MOUTVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12075 E STATE ROUTE 69
Mailing Address - Street 2:
Mailing Address - City:DEWEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86327-4517
Mailing Address - Country:US
Mailing Address - Phone:928-772-1673
Mailing Address - Fax:
Practice Address - Street 1:12075 E STATE ROUTE 69
Practice Address - Street 2:
Practice Address - City:DEWEY
Practice Address - State:AZ
Practice Address - Zip Code:86327-4517
Practice Address - Country:US
Practice Address - Phone:928-772-1673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant