Provider Demographics
NPI:1649234899
Name:GANGLOFF, HEATHER S (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:S
Last Name:GANGLOFF
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 1:330 BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:MA
Mailing Address - Zip Code:01742-2129
Mailing Address - Country:US
Mailing Address - Phone:978-287-9300
Mailing Address - Fax:
Practice Address - Street 1:330 BAKER AVE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-2129
Practice Address - Country:US
Practice Address - Phone:978-287-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1273363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP32631Medicare UPIN
MAAP1477Medicare ID - Type Unspecified