Provider Demographics
NPI:1508811522
Name:TATUM, HEIDI LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYNN
Last Name:TATUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:L
Other - Last Name:BRUGGEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 602108
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2108
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:87 SPRINGVIEW LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-9077
Practice Address - Country:US
Practice Address - Phone:843-876-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01173877OtherRR-MEDICARE
SCGP1551OtherMEDICAID GROUP
SC0526PAMedicaid
SCGP1551OtherMEDICAID GROUP
SCP01173877OtherRR-MEDICARE
SC0526PAMedicaid