Provider Demographics
NPI:1518215094
Name:MCCALL, HEATHER (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MCCALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23968
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-3968
Mailing Address - Country:US
Mailing Address - Phone:254-741-6333
Mailing Address - Fax:254-741-6364
Practice Address - Street 1:405 LONDONDERRY DR
Practice Address - Street 2:SUITE 301
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7924
Practice Address - Country:US
Practice Address - Phone:254-741-6333
Practice Address - Fax:254-741-6364
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07917363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00N59XOtherBCBS TEXAS
TX084249401Medicaid
TX00N59XOtherBCBS TEXAS