Provider Demographics
NPI:1649613076
Name:HETLAND, TIA KAY (PA-C)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:KAY
Last Name:HETLAND
Suffix:
Gender:F
Credentials: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:PO BOX 818
Mailing Address - Street 2:
Mailing Address - City:PLATTE
Mailing Address - State:SD
Mailing Address - Zip Code:57369-0818
Mailing Address - Country:US
Mailing Address - Phone:605-337-3364
Mailing Address - Fax:605-337-3360
Practice Address - Street 1:601 E 7TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:PLATTE
Practice Address - State:SD
Practice Address - Zip Code:57369-2123
Practice Address - Country:US
Practice Address - Phone:605-337-3364
Practice Address - Fax:605-337-3360
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS107304OtherMEDICARE PTAN