Provider Demographics
NPI:1770838948
Name:DERADE, HEIDI (IDMT)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:DERADE
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:GOLDMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:IDMT
Mailing Address - Street 1:5955 ZEAMER AVE
Mailing Address - Street 2:
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:907-551-9009
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-551-9009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians