Provider Demographics
NPI:1245497593
Name:HEADER, JULIE A (DO)
Entity type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:A
Last Name:HEADER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 512
Mailing Address - Street 2:
Mailing Address - City:MYERSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17067-0512
Mailing Address - Country:US
Mailing Address - Phone:717-376-3075
Mailing Address - Fax:844-252-3899
Practice Address - Street 1:36 W MAIN AVE
Practice Address - Street 2:
Practice Address - City:MYERSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17067-1121
Practice Address - Country:US
Practice Address - Phone:717-376-3075
Practice Address - Fax:844-252-3899
Is Sole Proprietor?:No
Enumeration Date:2008-05-22
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014952207Q00000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1025297500002Medicaid