Provider Demographics
NPI:1467583906
Name:WILANTEWICZ, HEATHER (RPA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WILANTEWICZ
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 S MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:WALDEN
Mailing Address - State:NY
Mailing Address - Zip Code:12586-1601
Mailing Address - Country:US
Mailing Address - Phone:845-778-5811
Mailing Address - Fax:845-778-5564
Practice Address - Street 1:142 S MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:WALDEN
Practice Address - State:NY
Practice Address - Zip Code:12586-1601
Practice Address - Country:US
Practice Address - Phone:845-778-5811
Practice Address - Fax:845-778-5564
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007210363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical