1962723718 NPI number — HEATHER DANIELLE LASETER PA-C

Table of content: HEATHER DANIELLE LASETER PA-C (NPI 1962723718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962723718 NPI number — HEATHER DANIELLE LASETER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LASETER
Provider First Name:
HEATHER
Provider Middle Name:
DANIELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STOVER
Provider Other First Name:
HEATHER
Provider Other Middle Name:
DANIELLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1962723718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 TECHNOLOGY PKWY NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30165-1369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
762-235-1000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 MARTHA BERRY BLVD NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30165-1625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-295-5331
Provider Business Practice Location Address Fax Number:
706-236-6432
Provider Enumeration Date:
06/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  005861 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 790821108A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 790821108D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 790821108E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 790821108C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 790821108F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 790821108B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 790821108G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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