Provider Demographics
NPI:1477988780
Name:ROACH, HEATHER LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:ROACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:PRAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8835 GERMANTOWN AVE OFC 217
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-2765
Mailing Address - Country:US
Mailing Address - Phone:215-248-7267
Mailing Address - Fax:
Practice Address - Street 1:8835 GERMANTOWN AVE OFC 217
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2765
Practice Address - Country:US
Practice Address - Phone:215-248-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056332363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical