Provider Demographics
NPI:1720179864
Name:PARK, HEATHER M (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:PARK
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 1:9021 ROUTE 210 HWY
Mailing Address - Street 2:
Mailing Address - City:SMICKSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16256-1925
Mailing Address - Country:US
Mailing Address - Phone:724-286-9740
Mailing Address - Fax:
Practice Address - Street 1:83 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2605
Practice Address - Country:US
Practice Address - Phone:814-938-3310
Practice Address - Fax:814-938-6804
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA-051107363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00179296Medicare ID - Type UnspecifiedRAILROAD MEDICARE
PA082420PTMMedicare ID - Type UnspecifiedMEDICARE
PAP71052Medicare UPIN