Provider Demographics
NPI:1366418113
Name:HEAP, LARRY TRAVIS (PA-C)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:TRAVIS
Last Name:HEAP
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1610
Mailing Address - Street 2:
Mailing Address - City:SPRINGERVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85938-1610
Mailing Address - Country:US
Mailing Address - Phone:928-333-5333
Mailing Address - Fax:928-333-5100
Practice Address - Street 1:606 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9813
Practice Address - Country:US
Practice Address - Phone:928-333-5333
Practice Address - Fax:928-333-5100
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3048363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ933467Medicaid
AZQ39417Medicare UPIN
AZZ101950Medicare PIN