Provider Demographics
NPI:1649282237
Name:RICKAWAY, HEATHER DAWN (PA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DAWN
Last Name:RICKAWAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 FLAG LAKE PLAZA
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566
Mailing Address - Country:US
Mailing Address - Phone:979-297-0362
Mailing Address - Fax:
Practice Address - Street 1:54 FLAG LAKE PLZ
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-6263
Practice Address - Country:US
Practice Address - Phone:979-297-0362
Practice Address - Fax:979-297-9096
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04624363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXQ61419Medicare UPIN
TX8G2701Medicare ID - Type Unspecified