Healthcare Provider Details

I. General information

NPI: 1508911850
Provider Name (Legal Business Name): HEATHER N DEMORY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 THOMAS JOHNSON DR STE C
FREDERICK MD
21702-4893
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 301-668-3004
  • Fax: 301-668-3005
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0002586
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002586
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: