Provider Demographics
NPI:1689836306
Name:HEIBEL, CARISSA LEIGH (PA)
Entity Type:Individual
Prefix:MISS
First Name:CARISSA
Middle Name:LEIGH
Last Name:HEIBEL
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-5100
Mailing Address - Fax:704-316-5101
Practice Address - Street 1:301 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-316-5100
Practice Address - Fax:704-316-5101
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2128363AS0400X
NC0010-04977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC187725OtherBCBS NC
TN1529055Medicaid
NCP01423324OtherMDCR RR
NC1689836306Medicaid
TNP01120793OtherRR MEDICARE
TN1529055Medicaid
NCNCJ519AMedicare PIN