Provider Demographics
NPI:1467452185
Name:ROBERTSON, HEATHER I (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:I
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CHURCH HILL RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LEEDS
Mailing Address - State:ME
Mailing Address - Zip Code:04263-3418
Mailing Address - Country:US
Mailing Address - Phone:207-524-3501
Mailing Address - Fax:207-524-2459
Practice Address - Street 1:180 CHURCH HILL RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LEEDS
Practice Address - State:ME
Practice Address - Zip Code:04263-3418
Practice Address - Country:US
Practice Address - Phone:207-524-3501
Practice Address - Fax:207-524-2459
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002587363A00000X
PAMA003586L363A00000X
MEPA1472363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1467452185Medicaid
ME1467452185Medicaid
PA050308Medicare ID - Type Unspecified
MEE400150349Medicare Oscar/Certification