Provider Demographics
NPI:1073990412
Name:DISSEK, HEATHER (MS)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:DISSEK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:ZAJAC-BEACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:4242 LEA RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226
Mailing Address - Country:US
Mailing Address - Phone:716-819-2408
Mailing Address - Fax:
Practice Address - Street 1:4242 LEA RIDGE ROAD
Practice Address - Street 2:SUITE 3
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226
Practice Address - Country:US
Practice Address - Phone:716-819-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY252Y00000XMedicare PIN