Provider Demographics
NPI:1891575221
Name:HEIDERSBERGER, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:HEIDERSBERGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1598 OAK CIR N
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-3478
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-205-4514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0008156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant