Provider Demographics
NPI:1285902494
Name:SMITH, HEATHER MARIE (PA)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:MARIE
Last Name:SMITH
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 1:25 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:MILL SPRING
Mailing Address - State:NC
Mailing Address - Zip Code:28756-0269
Mailing Address - Country:US
Mailing Address - Phone:661-373-4769
Mailing Address - Fax:
Practice Address - Street 1:419 EARL RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-6700
Practice Address - Country:US
Practice Address - Phone:704-481-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-02
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant