Provider Demographics
NPI:1104002948
Name:VIOLA, HEATHER LENA (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LENA
Last Name:VIOLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LENA
Other - Last Name:MAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:170 ARLINGTON PL APT B2
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-8188
Mailing Address - Country:US
Mailing Address - Phone:970-376-0386
Mailing Address - Fax:
Practice Address - Street 1:181 W MEADOW DR STE 400
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5058
Practice Address - Country:US
Practice Address - Phone:970-476-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2075363AS0400X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG57362Medicare UPIN
COP00446800Medicare PIN
COC801700Medicare PIN