Provider Demographics
NPI:1811182710
Name:JUSTICE, HEATHER CARLSON (MSPAP, PA-C)
Entity type:Individual
Prefix:MISS
First Name:HEATHER
Middle Name:CARLSON
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:MSPAP, PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:RUTH
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:KINGSPORT
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:130 W RAVINE RD
Practice Address - Street 2:KINGSPORT
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3837
Practice Address - Country:US
Practice Address - Phone:423-224-3150
Practice Address - Fax:423-224-3169
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05331363A00000X
MI5601006938363A00000X
TN2863363A00000X
VA0110005244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant