Provider Demographics
NPI:1235190273
Name:HEISER, PATRICK R (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:R
Last Name:HEISER
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:PO BOX 5116
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5116
Mailing Address - Country:US
Mailing Address - Phone:605-331-5890
Mailing Address - Fax:605-336-3974
Practice Address - Street 1:810 E 23RD ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-2135
Practice Address - Country:US
Practice Address - Phone:605-331-5890
Practice Address - Fax:605-336-3974
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0494363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6823652Medicaid
SDS101464Medicare PIN
SD6823652Medicaid