Provider Demographics
NPI:1376979765
Name:LEA, HEATHER V (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:V
Last Name:LEA
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 1:85 JOHN ST
Mailing Address - Street 2:APT 11M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-2823
Mailing Address - Country:US
Mailing Address - Phone:610-393-9414
Mailing Address - Fax:
Practice Address - Street 1:170 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2612
Practice Address - Country:US
Practice Address - Phone:212-312-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23016978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant