Provider Demographics
NPI:1689006819
Name:ELLEDGE, HEATHER H (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:H
Last Name:ELLEDGE
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 1:1154 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2583
Mailing Address - Country:US
Mailing Address - Phone:248-225-4408
Mailing Address - Fax:
Practice Address - Street 1:1154 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2583
Practice Address - Country:US
Practice Address - Phone:805-395-3277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23119207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine