Provider Demographics
NPI:1922150580
Name:DYER, HEIDI SUSANNE (PA)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:SUSANNE
Last Name:DYER
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:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29345 SW TOWN CENTER LOOP E
Practice Address - Street 2:SUITE 110
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-8486
Practice Address - Country:US
Practice Address - Phone:503-582-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01447363A00000X
IDPA652363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500609968Medicaid
IDCK5527Medicare PIN
ID1665108Medicare PIN
ORR170417Medicare PIN