Provider Demographics
NPI:1063575249
Name:GOLDFUSS, HEATHER LYLES (PA-C)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYLES
Last Name:GOLDFUSS
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 1:924 N HOWE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-3038
Mailing Address - Country:US
Mailing Address - Phone:910-457-3800
Mailing Address - Fax:910-457-3842
Practice Address - Street 1:4700 E OAK ISLAND DR
Practice Address - Street 2:
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28465-5257
Practice Address - Country:US
Practice Address - Phone:910-278-6416
Practice Address - Fax:855-763-1167
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01344363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1063575249OtherNPI 1063575249
SCD176888171Medicare ID - Type Unspecified
SC104247Medicaid