Provider Demographics
NPI:1285700807
Name:HAZLETT, HEATHER GERSBACHER (RPA C)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:GERSBACHER
Last Name:HAZLETT
Suffix:
Gender:F
Credentials:RPA C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:GERSBACHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA C
Mailing Address - Street 1:1803 MOUNT ROSE AVE
Mailing Address - Street 2:SUITE B3
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-3026
Mailing Address - Country:US
Mailing Address - Phone:717-851-1405
Mailing Address - Fax:717-812-4092
Practice Address - Street 1:25 MONUMENT RD
Practice Address - Street 2:SUITE 290
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5060
Practice Address - Country:US
Practice Address - Phone:717-812-4090
Practice Address - Fax:717-812-4092
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006869363A00000X, 363AS0400X
PAMA053963363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2130941OtherHIGHMARK BLUE SHIELD
NY02199948Medicaid
PA1585197OtherGATEWAY-WMG
S86582Medicare UPIN
PAP00883466Medicare PIN
PA164586FLTMedicare PIN
NY02199948Medicaid