Provider Demographics
NPI:1003048620
Name:HECK, TINA LISA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LISA
Last Name:HECK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:LISA
Other - Last Name:PRAVONGVIENGKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:77 CASA ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5806
Practice Address - Country:US
Practice Address - Phone:805-269-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-14
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20461363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant