Provider Demographics
NPI:1053628164
Name:BEKO, HEATHER N (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:N
Last Name:BEKO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:N
Other - Last Name:RAESKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7950 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE 2121
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:260-203-9602
Practice Address - Street 1:10343 DAWSONS CREEK BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1906
Practice Address - Country:US
Practice Address - Phone:260-203-9600
Practice Address - Fax:260-203-9602
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400069659Medicare PIN