Provider Demographics
NPI:1295154516
Name:WARREN, HEATHER (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
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 1:2800 S TEXAS AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5361
Mailing Address - Country:US
Mailing Address - Phone:936-266-3513
Mailing Address - Fax:713-852-2332
Practice Address - Street 1:2801 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-2544
Practice Address - Country:US
Practice Address - Phone:979-776-2537
Practice Address - Fax:979-776-2526
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1789363AM0700X
TXPA10148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353388702Medicaid