Healthcare Provider Details

I. General information

NPI: 1720319452
Provider Name (Legal Business Name): HEATHER KOHLI-WERNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 CATHAGE RD
BERLIN MD
21811
US

IV. Provider business mailing address

100 E CARROLL ST
SALISBURY MD
21801-5422
US

V. Phone/Fax

Practice location:
  • Phone: 410-912-6104
  • Fax: 410-208-1872
Mailing address:
  • Phone: 410-543-7531
  • Fax: 410-912-6386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0000888
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003851
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006714
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1088241
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: