Provider Demographics
NPI:1467418558
Name:PETT TAYLOR, HEATHER CHRISTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:CHRISTINE
Last Name:PETT TAYLOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 MAIN ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6788
Mailing Address - Country:US
Mailing Address - Phone:651-342-1039
Mailing Address - Fax:651-342-1428
Practice Address - Street 1:270 MAIN ST N STE 300
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6788
Practice Address - Country:US
Practice Address - Phone:651-342-1039
Practice Address - Fax:651-342-1428
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46825207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO31OtherTRICARE WEST
MN135959OtherUCARE
MN964678700Medicaid
MN517T3PEOtherBCBSMN
01-19132OtherMEDICA
MN964678700Medicaid
MN080013468Medicare ID - Type Unspecified