Provider Demographics
NPI:1598251308
Name:GRAY, HEATHER L (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:GRAY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:HORGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:270 MAIN ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6788
Mailing Address - Country:US
Mailing Address - Phone:651-342-1039
Mailing Address - Fax:651-342-1428
Practice Address - Street 1:270 MAIN ST N STE 300
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6788
Practice Address - Country:US
Practice Address - Phone:651-342-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4895363A00000X
363A00000X
MN12742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant