Healthcare Provider Details

I. General information

NPI: 1811416951
Provider Name (Legal Business Name): HEATHER MICHAELA DOUGLAS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 INDIANA AVE
LUBBOCK TX
79415-3364
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3545
US

V. Phone/Fax

Practice location:
  • Phone: 806-761-0566
  • Fax: 806-744-7252
Mailing address:
  • Phone: 806-761-0360
  • Fax: 806-782-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11486
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: