Healthcare Provider Details

I. General information

NPI: 1619021250
Provider Name (Legal Business Name): DEMETRA LATRICE TATE-HEILMAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 FIRST COLONIAL RD
VIRGINIA BEACH VA
23454-3002
US

IV. Provider business mailing address

2800 GODWIN BLVD
SUFFOLK VA
23434-8038
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-2323
  • Fax:
Mailing address:
  • Phone: 757-934-4821
  • Fax: 757-934-4276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002414
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: