Healthcare Provider Details

I. General information

NPI: 1437382157
Provider Name (Legal Business Name): HEATHER MARIE DEDERMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER MARIE YOUNG PA-C

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W NORFOLK AVE
NORFOLK NE
68701-4438
US

IV. Provider business mailing address

2700 W NORFOLK AVE
NORFOLK NE
68701-4438
US

V. Phone/Fax

Practice location:
  • Phone: 402-644-7543
  • Fax: 402-644-7503
Mailing address:
  • Phone: 402-644-7543
  • Fax: 402-644-7503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1449
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: