Provider Demographics
NPI:1578601506
Name:SMITH, HEATHER MARIE (PA C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MARIE
Other - Last Name:CLANCY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:P A C
Mailing Address - Street 1:4220 BULL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6026
Mailing Address - Country:US
Mailing Address - Phone:512-617-7500
Mailing Address - Fax:
Practice Address - Street 1:4220 BULL CREEK RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6026
Practice Address - Country:US
Practice Address - Phone:512-617-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02937363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP81440Medicare UPIN
TX8A4015Medicare ID - Type UnspecifiedMEDICARE GROUP 00765U