Provider Demographics
NPI:1962083162
Name:HELLER, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HELLER
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 1:106 2ND ST N
Mailing Address - Street 2:
Mailing Address - City:BRADENTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:34217-2434
Mailing Address - Country:US
Mailing Address - Phone:941-518-6868
Mailing Address - Fax:
Practice Address - Street 1:2430 W PIERCE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-3553
Practice Address - Country:US
Practice Address - Phone:575-887-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013312367500000X
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program