Basic Information
| Provider Information | |||||||||
| NPI: | 1063575249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDFUSS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | LYLES | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 924 N HOWE ST | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284613038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104573800 | ||||||||
| FaxNumber: | 9104573842 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 E OAK ISLAND DR | ||||||||
| Address2: | |||||||||
| City: | OAK ISLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284655257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102786416 | ||||||||
| FaxNumber: | 8557631167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-01344 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1063575249 | 01 | NC | NPI 1063575249 | OTHER |