Provider Demographics
NPI:1306973425
Name:HEADY, CAMERON WAYNE (PA-C)
Entity type:Individual
Prefix:MR
First Name:CAMERON
Middle Name:WAYNE
Last Name:HEADY
Suffix:
Gender:M
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 1:457 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-1360
Mailing Address - Country:US
Mailing Address - Phone:931-738-3383
Mailing Address - Fax:931-738-8911
Practice Address - Street 1:457 VISTA DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:TN
Practice Address - Zip Code:38583-1360
Practice Address - Country:US
Practice Address - Phone:931-738-3383
Practice Address - Fax:931-738-8911
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1441363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3665152Medicaid
TN3665152Medicare PIN