Provider Demographics
NPI:1740837038
Name:VON HERTLEIN, HEIDI NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:NICOLE
Last Name:VON HERTLEIN
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 1:608 MEADOWLARK LN
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-2521
Mailing Address - Country:US
Mailing Address - Phone:805-794-1294
Mailing Address - Fax:
Practice Address - Street 1:2702 8TH AVE N
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-1107
Practice Address - Country:US
Practice Address - Phone:406-238-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT921363A00000X
MTMED-PAC-LIC-103215363A00000X, 363AS0400X
WYPA921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant