Provider Demographics
NPI:1811998628
Name:HEATON, THEA (PA-C)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:HEATON
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 1:318 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3765
Mailing Address - Country:US
Mailing Address - Phone:208-467-3006
Mailing Address - Fax:208-467-1155
Practice Address - Street 1:318 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3765
Practice Address - Country:US
Practice Address - Phone:208-467-3006
Practice Address - Fax:208-467-1155
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00597363A00000X
IDPA474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ03000Medicare UPIN