Provider Demographics
NPI:1720319452
Name:KOHLI-WERNER, HEATHER (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KOHLI-WERNER
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 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-543-7531
Mailing Address - Fax:410-912-6386
Practice Address - Street 1:11101 CATHAGE RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-912-6104
Practice Address - Fax:410-208-1872
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000888363A00000X
VA0110003851363A00000X
MDC0006714363A00000X
OH1088241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1720319452Medicaid
VAVV7067AMedicare PIN
VAP01093559Medicare PIN