Provider Demographics
NPI:1164649471
Name:TACKETT, HEATHER D (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:D
Last Name:TACKETT
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:PO BOX 4024
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4024
Mailing Address - Country:US
Mailing Address - Phone:417-885-3888
Mailing Address - Fax:417-881-7268
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:WEST TOWER, SUITE 700
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-885-3888
Practice Address - Fax:417-881-7268
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007003918363A00000X, 363AS0400X
ARPA-405363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO# PENDINGMedicare UPIN
MO000097454Medicare PIN