Provider Demographics
NPI:1114965647
Name:ROLLINS, HEATHER M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:M
Last Name:ROLLINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 20130
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97307-0130
Mailing Address - Country:US
Mailing Address - Phone:503-393-2533
Mailing Address - Fax:503-393-5978
Practice Address - Street 1:5100 RIVER RD N
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5371
Practice Address - Country:US
Practice Address - Phone:503-393-2533
Practice Address - Fax:503-393-5978
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
ORPA01362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR158194OtherMEDICARE PTAN
ORR158194OtherMEDICARE PTAN