Provider Demographics
NPI:1861901530
Name:HEADY, NATHAN KYLE (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:KYLE
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:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:618-724-4628
Practice Address - Street 1:7211 US 45 S
Practice Address - Street 2:
Practice Address - City:CARRIER MILLS
Practice Address - State:IL
Practice Address - Zip Code:62917-1305
Practice Address - Country:US
Practice Address - Phone:833-209-0498
Practice Address - Fax:618-724-4628
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC654363A00000X
IL085006959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant