Provider Demographics
NPI:1336419829
Name:PRUSIK, HEATHER LEWIS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LEWIS
Last Name:PRUSIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:PRUSIK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2675 N DECATUR RD STE 601
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6134
Mailing Address - Country:US
Mailing Address - Phone:404-501-2900
Mailing Address - Fax:
Practice Address - Street 1:2675 N DECATUR RD STE 601
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6134
Practice Address - Country:US
Practice Address - Phone:404-501-2900
Practice Address - Fax:404-501-2992
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant