Basic Information
| Provider Information | |||||||||
| NPI: | 1568903391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAFFEO | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA-C, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 601495 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242454 | ||||||||
| Practice Location | |||||||||
| Address1: | 316 CALHOUN STREET | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294011113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437242010 | ||||||||
| FaxNumber: | 8437242005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2017 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 2000006538 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363AM0700X | 1143416 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 36670 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3040PA | 05 | SC | MEDICAID |