Provider Demographics
NPI:1245616440
Name:HEASTON, LAUREN G (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:G
Last Name:HEASTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LAUREN
Other - Middle Name:G
Other - Last Name:O'BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2020 WALNUT ST APT 7D
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5637
Mailing Address - Country:US
Mailing Address - Phone:309-339-5746
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:215-590-2204
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant