Provider Demographics
NPI:1801370150
Name:GLIEM, HEATHER MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:GLIEM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MICHELLE
Other - Last Name:HERRMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 UTAH ST
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:KS
Mailing Address - Zip Code:66434-2314
Mailing Address - Country:US
Mailing Address - Phone:785-742-2131
Mailing Address - Fax:
Practice Address - Street 1:300 UTAH ST FL 2
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2314
Practice Address - Country:US
Practice Address - Phone:785-742-2161
Practice Address - Fax:785-742-6554
Is Sole Proprietor?:No
Enumeration Date:2018-09-22
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201223150AMedicaid