Provider Demographics
NPI:1235192840
Name:NATIVO, HEIDI J (PA C)
Entity Type:Individual
Prefix:MRS
First Name:HEIDI
Middle Name:J
Last Name:NATIVO
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MRS
Other - First Name:HEIDI
Other - Middle Name:J
Other - Last Name:NATIVO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:253 CAPRI TER
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-2441
Mailing Address - Country:US
Mailing Address - Phone:201-819-4586
Mailing Address - Fax:
Practice Address - Street 1:1 BAY AVE
Practice Address - Street 2:HUMC @ MOUNTAINSIDE HOSPITAL
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4837
Practice Address - Country:US
Practice Address - Phone:973-429-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00011200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S32304Medicare UPIN
NJ021625Medicare ID - Type Unspecified