Provider Demographics
NPI:1356791339
Name:HEREDIA, CAITLIN B
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:B
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 STARTOWN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-8307
Mailing Address - Country:US
Mailing Address - Phone:828-327-4745
Mailing Address - Fax:828-322-3569
Practice Address - Street 1:1985 STARTOWN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-8307
Practice Address - Country:US
Practice Address - Phone:828-327-4745
Practice Address - Fax:828-322-3569
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant