Basic Information
Provider Information | |||||||||
NPI: | 1952588782 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SICKAFOOSE | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CARMIEN | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3640 NEW VISION DR | ||||||||
Address2: | SUITE A | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468451716 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604824440 | ||||||||
FaxNumber: | 2604824442 | ||||||||
Practice Location | |||||||||
Address1: | 2200 RANDALLIA DR | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468054638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2603734000 | ||||||||
FaxNumber: | 2604824442 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2008 | ||||||||
LastUpdateDate: | 04/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10000962A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.