Provider Demographics
NPI:1770536344
Name:KOHOUT, HEATHER J (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:J
Last Name:KOHOUT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:J
Other - Last Name:VATLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8550 W 38TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4355
Mailing Address - Country:US
Mailing Address - Phone:303-463-3900
Mailing Address - Fax:303-423-2621
Practice Address - Street 1:8550 W 38TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4355
Practice Address - Country:US
Practice Address - Phone:303-463-3900
Practice Address - Fax:303-423-2621
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3430363A00000X
IL085002714363A00000X
IL85002714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL809840OtherMEDICARE GROUP
ILCA4079OtherRR MEDICARE GROUP PTAN
IL371221637OtherFEDERAL TAX ID
776530OtherMEDICARE GROUP PIN
ILP00680137OtherRR MEDICARE MEMBER PTAN
776530OtherMEDICARE GROUP PIN
K39061Medicare PIN
ILP00680137OtherRR MEDICARE MEMBER PTAN