Provider Demographics
NPI:1770942369
Name:COLLAZO, HEATHER CHRISTEN (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:CHRISTEN
Last Name:COLLAZO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:CHRISTEN
Other - Last Name:HART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12416 66TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-3430
Mailing Address - Country:US
Mailing Address - Phone:727-547-4700
Mailing Address - Fax:727-394-8661
Practice Address - Street 1:12416 66TH ST STE A
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-3430
Practice Address - Country:US
Practice Address - Phone:727-547-4700
Practice Address - Fax:727-394-8661
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109347363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical