Provider Demographics
NPI:1629645635
Name:HETENIAK, VERONIKA MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:VERONIKA
Middle Name:MAE
Last Name:HETENIAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12660 RIVERSIDE DR STE 225
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3469
Mailing Address - Country:US
Mailing Address - Phone:818-755-0265
Mailing Address - Fax:818-753-9074
Practice Address - Street 1:12660 RIVERSIDE DR STE 225
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3469
Practice Address - Country:US
Practice Address - Phone:818-755-0265
Practice Address - Fax:818-753-9074
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty