Provider Demographics
NPI:1962723718
Name:LASETER, HEATHER DANIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:DANIELLE
Last Name:LASETER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DANIELLE
Other - Last Name:STOVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:706-295-5331
Practice Address - Fax:706-236-6432
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA790821108AMedicaid
GA790821108DMedicaid
GA790821108EMedicaid
GA790821108CMedicaid
GA790821108FMedicaid
GA790821108BMedicaid
GA790821108GMedicaid
GA790821108FMedicaid