Provider Demographics
NPI:1679931083
Name:ANDERSON, HEATHER M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:M
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:HEATHER
Other - Middle Name:M
Other - Last Name:DUHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2080 S FRONTAGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180
Mailing Address - Country:US
Mailing Address - Phone:601-262-1000
Mailing Address - Fax:601-630-9994
Practice Address - Street 1:2080 S FRONTAGE RD STE 100
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180
Practice Address - Country:US
Practice Address - Phone:601-262-1000
Practice Address - Fax:601-630-9994
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-01
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00267363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical