Basic Information
| Provider Information | |||||||||
| NPI: | 1518936517 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | MR 10202 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122621166 | ||||||||
| FaxNumber: | 6122624258 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 ST. JOHNS BLVD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551091190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518425355 | ||||||||
| FaxNumber: | 6517709153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 9587 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 9587 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 101656300 | 05 | MN | MEDICAID |