1891017125 NPI number — HEATHER MARIE ELLIOTT DEMARS PA-C

Table of content: HEATHER MARIE ELLIOTT DEMARS PA-C (NPI 1891017125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891017125 NPI number — HEATHER MARIE ELLIOTT DEMARS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT DEMARS
Provider First Name:
HEATHER
Provider Middle Name:
MARIE
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:
DEMARS
Provider Other First Name:
HEATHER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1891017125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
260 BICENTENNIAL WAY APT 811
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403-7423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-959-8758
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3495 KEYSTONE LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DISCOVERY BAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94505-2320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-959-8758
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2010

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:  PA-261 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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