Provider Demographics
NPI:1043300205
Name:DALE, HEATHER A (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:DALE
Suffix:
Gender:F
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 1:800 W COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-1485
Mailing Address - Country:US
Mailing Address - Phone:507-933-7630
Mailing Address - Fax:507-933-6074
Practice Address - Street 1:800 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082-1485
Practice Address - Country:US
Practice Address - Phone:507-933-7630
Practice Address - Fax:507-933-6074
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA504363A00000X
MN10324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10324OtherMN STATE LICENSE NUMBER
IDPA504OtherSTATE LICENSE #