Provider Demographics
NPI:1174686448
Name:MISJA, HEATHER MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:MISJA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MARIE
Other - Last Name:DOLLENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4112 OUTLOOK BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1667
Mailing Address - Country:US
Mailing Address - Phone:719-475-9496
Mailing Address - Fax:
Practice Address - Street 1:1625 MEDICAL CENTER PT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-8731
Practice Address - Country:US
Practice Address - Phone:719-475-9496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2010-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052759363AM0700X
CO2937363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical