Provider Demographics
NPI:1811380009
Name:OLDHAM, HEATHER AMANDA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:AMANDA
Last Name:OLDHAM
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 1:7019 N PIERCE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5017
Mailing Address - Country:US
Mailing Address - Phone:517-505-2221
Mailing Address - Fax:
Practice Address - Street 1:1035 NW NORTHRUP ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3017
Practice Address - Country:US
Practice Address - Phone:971-303-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant