Provider Demographics
NPI:1841244993
Name:STACK, HEATHER L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:L
Last Name:STACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:L
Other - Last Name:BILLINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3200 PLEASANT VALLEY RD
Mailing Address - Street 2:PLASTIC SURGERY
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9274
Mailing Address - Country:US
Mailing Address - Phone:262-836-7344
Mailing Address - Fax:262-836-7372
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:PLASTIC SURGERY
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-836-7344
Practice Address - Fax:262-836-7372
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1541363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
008000261JOtherHUMANA
WI1841244993Medicaid
P71332Medicare UPIN
WI010N 73-601Medicare PIN