Provider Demographics
NPI:1861635336
Name:OKUN DEMUTH, HEATHER E (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:OKUN DEMUTH
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 1:201 HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKS GREEN
Mailing Address - State:PA
Mailing Address - Zip Code:18411-1115
Mailing Address - Country:US
Mailing Address - Phone:570-430-1779
Mailing Address - Fax:
Practice Address - Street 1:1208 ONEILL HWY
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18512-1709
Practice Address - Country:US
Practice Address - Phone:570-207-2612
Practice Address - Fax:570-207-2616
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053579363A00000X
PAOA002361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA276070ZCPNMedicare PIN