Provider Demographics
NPI:1104860774
Name:HEATH, JERRY ANDERSON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ANDERSON
Last Name:HEATH
Suffix:
Gender:M
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 1:5229 ROCK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:NC
Mailing Address - Zip Code:28635-9267
Mailing Address - Country:US
Mailing Address - Phone:336-696-2711
Mailing Address - Fax:336-696-2829
Practice Address - Street 1:5229 ROCK CREEK RD
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:NC
Practice Address - Zip Code:28635-9267
Practice Address - Country:US
Practice Address - Phone:336-696-2711
Practice Address - Fax:336-696-2829
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2743923DMedicare ID - Type Unspecified
NCS41955Medicare UPIN