Provider Demographics
NPI:1518929207
Name:NGO, HEATHER LEA (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEA
Last Name:NGO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LEA
Other - Last Name:DWYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:13201 WALSINGHAM RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-3515
Mailing Address - Country:US
Mailing Address - Phone:727-261-1754
Mailing Address - Fax:
Practice Address - Street 1:13201 WALSINGHAM RD STE 200
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774
Practice Address - Country:US
Practice Address - Phone:727-261-1754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102254363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00080046OtherRAILROAD MEDICARE
FL291532400Medicaid
FL291532400Medicaid
P80669Medicare UPIN
U0150Medicare ID - Type Unspecified