Provider Demographics
NPI:1811940729
Name:BARON, HEATHER SPOHN (PAC)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:SPOHN
Last Name:BARON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14760 31 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48095-1503
Mailing Address - Country:US
Mailing Address - Phone:248-722-8298
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:800-653-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X, 363AS0400X
MI5601004284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1062339OtherNCCPA CERTIFICATE NUMBER