Provider Demographics
NPI:1104869569
Name:UPCHURCH, HEATHER C (PA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:C
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 W 94TH PLACE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1710
Mailing Address - Country:US
Mailing Address - Phone:219-662-8822
Mailing Address - Fax:219-662-8833
Practice Address - Street 1:70 W 94TH PLACE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-1710
Practice Address - Country:US
Practice Address - Phone:219-662-8822
Practice Address - Fax:219-662-8833
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000889A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00477948Medicare PIN
IN234710DMedicare PIN