Provider Demographics
NPI:1518912971
Name:MATA, HEATHER LYNNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYNNE
Last Name:MATA
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 1:3495 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5501
Mailing Address - Country:US
Mailing Address - Phone:812-220-4755
Mailing Address - Fax:812-231-4475
Practice Address - Street 1:3495 S 4TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5501
Practice Address - Country:US
Practice Address - Phone:812-220-4755
Practice Address - Fax:812-231-4475
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001212A363AM0700X
MI5601002771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0852915110OtherBC PIN
MI1010612OtherMCLAREN
MIM02890P04Medicare PIN
MIM17400018Medicare PIN
MI0852915110OtherBC PIN