Provider Demographics
NPI:1093236812
Name:HELLER, CHANNING JOHN
Entity Type:Individual
Prefix:
First Name:CHANNING
Middle Name:JOHN
Last Name:HELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 MEDICAL CENTER DRIVE
Mailing Address - Street 2:ATTN: EMERGENCY DEPARTMENT
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939
Mailing Address - Country:US
Mailing Address - Phone:540-332-4423
Mailing Address - Fax:540-332-5658
Practice Address - Street 1:78 MEDICAL CENTER DRIVE
Practice Address - Street 2:ATTN: EMERGENCY DEPARTMENT
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939
Practice Address - Country:US
Practice Address - Phone:540-332-4423
Practice Address - Fax:540-332-5658
Is Sole Proprietor?:No
Enumeration Date:2017-07-01
Last Update Date:2017-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005824363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical