Provider Demographics
NPI:1629080247
Name:BARRETT, HEATHER M (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:BARRETT
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53141-0130
Mailing Address - Country:US
Mailing Address - Phone:262-656-2718
Mailing Address - Fax:262-656-2749
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5031
Practice Address - Country:US
Practice Address - Phone:262-656-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2017023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI391888660006OtherANTHEM
WI42892300Medicaid
WI391888660006OtherANTHEM