Provider Demographics
NPI:1790718070
Name:WITTMANN, HEATHER C (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:WITTMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DHMC- GIM
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-653-9500
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-653-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0301363AM0700X
VT055-0030388363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30011103Medicaid
NH0301OtherLICENSE
VT055-0030388OtherLICENSE
VT2002091Medicaid
NHAP0945Medicare ID - Type Unspecified
NH30011103Medicaid