Basic Information
| Provider Information | |||||||||
| NPI: | 1144716606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIVENS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 556 3RD ST STE A | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312017993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787432472 | ||||||||
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| Practice Location | |||||||||
| Address1: | 556 3RD ST STE A | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312017993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787432472 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2018 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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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 | 363A00000X | 8812 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1153909 | 01 | GA | NCCPA CERTIFICATION | OTHER | 8812 | 01 | GA | PA LICENSE NUMBER | OTHER |