Provider Demographics
NPI:1932478575
Name:DE OLIVEIRA, HEBER J (CSA)
Entity Type:Individual
Prefix:
First Name:HEBER
Middle Name:J
Last Name:DE OLIVEIRA
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14103 CORUNNA CT
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6901
Mailing Address - Country:US
Mailing Address - Phone:301-531-4554
Mailing Address - Fax:
Practice Address - Street 1:14103 CORUNNA CT
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-6901
Practice Address - Country:US
Practice Address - Phone:301-531-4554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
DCSA0117363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant