Provider Demographics
NPI:1124783774
Name:HEISER, JACOB (PA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HEISER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 S STATE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4112
Mailing Address - Country:US
Mailing Address - Phone:302-261-5600
Mailing Address - Fax:302-450-3181
Practice Address - Street 1:1113 S STATE ST STE 202
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4112
Practice Address - Country:US
Practice Address - Phone:302-261-5600
Practice Address - Fax:302-450-3181
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC50011629OtherDE PROFESSIONAL LICENSE