Provider Demographics
NPI:1578815932
Name:CLOUSE, HEATHER CHRISTIAN (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:CHRISTIAN
Last Name:CLOUSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 BRECKENRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1089
Mailing Address - Country:US
Mailing Address - Phone:270-684-0028
Mailing Address - Fax:270-685-8233
Practice Address - Street 1:1200 BRECKENRIDGE ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1089
Practice Address - Country:US
Practice Address - Phone:270-683-7553
Practice Address - Fax:270-685-8226
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC153363A00000X
KYPA1762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100223100Medicaid