Provider Demographics
NPI:1649819731
Name:FISKE, HEATHER E (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:E
Last Name:FISKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:E
Other - Last Name:TETTELBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:STE 1022
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5530
Mailing Address - Country:US
Mailing Address - Phone:203-200-8187
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST STE 1003
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5529
Practice Address - Country:US
Practice Address - Phone:860-696-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4682363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant