Provider Demographics
NPI:1508836990
Name:DECKER, HEATHER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:734-747-6766
Mailing Address - Fax:734-222-3100
Practice Address - Street 1:7575 GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9309
Practice Address - Country:US
Practice Address - Phone:810-844-7290
Practice Address - Fax:810-844-7295
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11-5-25-1236-0OtherBLUE CROSS OF MICHIGAN
MI0B56404-007Medicare ID - Type Unspecified
MI0B56404-007Medicare PIN
MIQ49283Medicare UPIN