Provider Demographics
NPI:1255394979
Name:TYRE, HEATHER F (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:F
Last Name:TYRE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:F
Other - Last Name:NESMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2400 BELLEVUE ROAD
Mailing Address - Street 2:SUITE 21-A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:980 SOUTH 1ST STREET
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545
Practice Address - Country:US
Practice Address - Phone:912-427-4267
Practice Address - Fax:912-559-2638
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004357363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA541791446Medicaid
GA541791446Medicaid