Provider Demographics
NPI:1558306035
Name:HEACOCK, ALISON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALISON
Middle Name:
Last Name:HEACOCK
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 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2640
Mailing Address - Country:US
Mailing Address - Phone:937-245-7100
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:725 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45324-2640
Practice Address - Country:US
Practice Address - Phone:937-245-7100
Practice Address - Fax:937-245-7999
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00322600363A00000X
OH002939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0072094Medicaid
OH0072094Medicaid
NJ523280ZURNMedicare PIN