MEDICARE: MS. HEATHER KONZELMANN 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	363A00000X	Physician Assistant	PA9103440	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Q54584	OTHER	FL	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1720066251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HEATHER KONZELMANN PA

Provider Business Mailing Address
First Line	:	101 W UNIVERSITY AVE
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61820-3909
Country	:	US
Telephone Number	:	217-366-8107
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 WINDSOR RD
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-6217
Country	:	US
Telephone Number	:	217-366-8130
Fax Number	:

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

Provider Enumeration Date	:	01/05/2006
Last Update Date	:	12/05/2014

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Directions to “ MS. HEATHER KONZELMANN PA” Practice Location

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