Provider Demographics
NPI:1922516483
Name:MIYASHIRO, HEATHER ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:MIYASHIRO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:HOSMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:18444 N 25TH AVE STE 210
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-1264
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-974-2673
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL2917363A00000X
WAPA61003115363A00000X
AZ6952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCC1479068OtherMEDICARE
SCSCC1478510OtherMEDICARE
SC3487PAMedicaid