Provider Demographics
NPI:1467509612
Name:HEETER, ANDREA (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:HEETER
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SANTO DOMINGO HEALTH CENTER
Mailing Address - Street 2:85 HWY 22
Mailing Address - City:SANTO DOMINGO
Mailing Address - State:NM
Mailing Address - Zip Code:87052
Mailing Address - Country:US
Mailing Address - Phone:505-465-3060
Mailing Address - Fax:
Practice Address - Street 1:SANTO DOMINGO HEALTH CENTER
Practice Address - Street 2:85 HWY 22
Practice Address - City:SANTO DOMINGO
Practice Address - State:NM
Practice Address - Zip Code:87052
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:505-465-1185
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FL9110591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer