Provider Demographics
NPI:1083685408
Name:HERON, KIRSTEN ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ANNE
Last Name:HERON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 NW RAINBOW RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-8722
Mailing Address - Country:US
Mailing Address - Phone:541-678-5277
Mailing Address - Fax:
Practice Address - Street 1:2564 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7638
Practice Address - Country:US
Practice Address - Phone:541-678-5277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500622201Medicaid
ORPA00936OtherLICENSE
ORPA00936OtherLICENSE
ORMH1033353OtherDEA
OR121117Medicare ID - Type UnspecifiedMEDICARE