MEDICARE: HEATHER DAWN RICKAWAY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA04624	TX

General Provider Information

NPI Number	:	1649282237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER DAWN RICKAWAY PA

Provider Business Mailing Address
First Line	:	54 FLAG LAKE PLAZA
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566
Country	:	US
Telephone Number	:	979-297-0362
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 FLAG LAKE PLZ
Second Line	:
City	:	LAKE JACKSON
State	:	TX
Zip	:	77566-6263
Country	:	US
Telephone Number	:	979-297-0362
Fax Number	:	979-297-9096

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	07/21/2010

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