Provider Demographics
NPI:1134319601
Name:HEICHEL, COREY A (PA-C)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:A
Last Name:HEICHEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 PRIMERA BLVD STE 1001
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-2191
Mailing Address - Country:US
Mailing Address - Phone:386-561-9967
Mailing Address - Fax:844-815-1446
Practice Address - Street 1:795 PRIMERA BLVD STE 1001
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-2191
Practice Address - Country:US
Practice Address - Phone:386-561-9967
Practice Address - Fax:844-815-1446
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2134363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1944PAMedicaid
SCSC42634560Medicare PIN