Provider Demographics
NPI:1487756243
Name:BENNETT, HEIDI LEEA (PA-C)
Entity type:Individual
Prefix:MS
First Name:HEIDI
Middle Name:LEEA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:HULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4659
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93403-4659
Mailing Address - Country:US
Mailing Address - Phone:805-544-7246
Mailing Address - Fax:805-782-8097
Practice Address - Street 1:3030 N CIRCLE DR STE 210
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-228-9440
Practice Address - Fax:719-228-9061
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA0002477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58821031Medicaid