Provider Demographics
NPI:1316992092
Name:PFAHLERT, HEATHER ELYSIA (PA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:ELYSIA
Last Name:PFAHLERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:ELYSIA
Other - Last Name:RUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:701 LUKE ST
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-9643
Mailing Address - Country:US
Mailing Address - Phone:252-482-6811
Mailing Address - Fax:
Practice Address - Street 1:701 LUKE ST
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-9643
Practice Address - Country:US
Practice Address - Phone:252-482-6811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2613363A00000X
COPA.0003546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ691023-03Medicaid
AZ691023-03Medicaid
AZP19235Medicare UPIN