Provider Demographics
NPI:1104580117
Name:HEETER, MARLEA (PA-C)
Entity type:Individual
Prefix:
First Name:MARLEA
Middle Name:
Last Name:HEETER
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 1:145 PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-3371
Mailing Address - Country:US
Mailing Address - Phone:814-723-8023
Mailing Address - Fax:814-723-8025
Practice Address - Street 1:145 PLEASANT DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-3371
Practice Address - Country:US
Practice Address - Phone:814-723-8023
Practice Address - Fax:814-723-8025
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063105363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1039807220001Medicaid