Provider Demographics
NPI:1356615835
Name:HERITAGE, REBECCA A (MMSC, PA-C)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:HERITAGE
Suffix:
Gender:F
Credentials:MMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 W RED BANK AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-1630
Mailing Address - Country:US
Mailing Address - Phone:856-845-0664
Mailing Address - Fax:856-845-7602
Practice Address - Street 1:17 W RED BANK AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1630
Practice Address - Country:US
Practice Address - Phone:856-845-0664
Practice Address - Fax:856-845-7602
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03424363A00000X, 363AS0400X
NJ25MP00318300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical