Basic Information
| Provider Information | |||||||||
| NPI: | 1720319452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOHLI-WERNER | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E CARROLL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218015422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105437531 | ||||||||
| FaxNumber: | 4109126386 | ||||||||
| Practice Location | |||||||||
| Address1: | 11101 CATHAGE RD | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109126104 | ||||||||
| FaxNumber: | 4102081872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 12/28/2018 | ||||||||
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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 | C5-0000888 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110003851 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C0006714 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1088241 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1720319452 | 05 | VA | MEDICAID |