Basic Information
Provider Information | |||||||||
NPI: | 1104187699 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSON | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | KIM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5221 PARAMOUNT PKWY STE 220 | ||||||||
Address2: |   | ||||||||
City: | MORRISVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 275605490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 115 KILDAIRE PARK DR STE 108 | ||||||||
Address2: |   | ||||||||
City: | CARY | ||||||||
State: | NC | ||||||||
PostalCode: | 275188144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194691252 | ||||||||
FaxNumber: | 9194691373 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/31/2012 | ||||||||
LastUpdateDate: | 11/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0116024405 | VA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2015-00354 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.