Provider Demographics
NPI:1508853136
Name:GARCIA, HEIDI RAE (PAC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:RAE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3228 W 154TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4016
Mailing Address - Country:US
Mailing Address - Phone:310-715-2185
Mailing Address - Fax:
Practice Address - Street 1:1141 W REDONDO BEACH BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-3586
Practice Address - Country:US
Practice Address - Phone:310-538-9400
Practice Address - Fax:310-538-0101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant