Provider Demographics
NPI:1023190477
Name:DAVIS, HEATHER HANES (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:HANES
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DENISE
Other - Last Name:HANES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:804 ENGLISH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-6027
Mailing Address - Country:US
Mailing Address - Phone:252-443-3133
Mailing Address - Fax:252-443-6726
Practice Address - Street 1:804 ENGLISH RD STE 100
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-6027
Practice Address - Country:US
Practice Address - Phone:252-443-3133
Practice Address - Fax:252-443-6726
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103803363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ27687Medicare UPIN