Provider Demographics
NPI:1871528083
Name:RUNGE, HEATHER L (PA-C)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:RUNGE
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 1:600 W SHELL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MINONG
Mailing Address - State:WI
Mailing Address - Zip Code:54859-9145
Mailing Address - Country:US
Mailing Address - Phone:715-466-2201
Mailing Address - Fax:715-466-2205
Practice Address - Street 1:600 W SHELL CREEK RD
Practice Address - Street 2:
Practice Address - City:MINONG
Practice Address - State:WI
Practice Address - Zip Code:54859-9145
Practice Address - Country:US
Practice Address - Phone:715-466-2201
Practice Address - Fax:715-466-2205
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1413363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P41768Medicare UPIN