Provider Demographics
NPI:1336172618
Name:HEESCHEN, AMY L (PAC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:HEESCHEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6110 ABBOT RD
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1410
Mailing Address - Country:US
Mailing Address - Phone:517-332-5342
Mailing Address - Fax:517-332-3325
Practice Address - Street 1:6110 ABBOT RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-1410
Practice Address - Country:US
Practice Address - Phone:517-332-5342
Practice Address - Fax:517-332-3325
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005171363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292349100Medicaid
FLPA9102667OtherLICENSE