Provider Demographics
NPI:1578507612
Name:TERRY, HEATHER BEASLEY (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:BEASLEY
Last Name:TERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNNE
Other - Last Name:BEASLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2785 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE100
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2515
Mailing Address - Country:US
Mailing Address - Phone:404-292-4612
Mailing Address - Fax:678-514-0088
Practice Address - Street 1:2785 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE100
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-2515
Practice Address - Country:US
Practice Address - Phone:404-292-4612
Practice Address - Fax:678-514-0088
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003743363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002705AMedicaid
GA97WCCLWMedicare PIN
GA100002705AMedicaid