Provider Demographics
NPI:1891744827
Name:BROCK, HEATHER SUZANNE (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:SUZANNE
Last Name:BROCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SAINT CLAIR PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1007
Mailing Address - Country:US
Mailing Address - Phone:678-446-7351
Mailing Address - Fax:
Practice Address - Street 1:100 SAINT CLAIR PKWY
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1007
Practice Address - Country:US
Practice Address - Phone:678-446-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003270363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97BBDXSMedicare ID - Type Unspecified