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General NPI Number Information
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NPI Number | 1063575249
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Entity Type | Individual
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Provider Name | HEATHER LYLES GOLDFUSS PA-C
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Gender | Female
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 03/22/2017
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Provider Practice Location Address
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Address Line | 4700 E OAK ISLAND DR
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City | OAK ISLAND
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State | NC
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Zip | 28465-5257
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Country | US
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Telephone | 910-278-6416
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Fax | 855-763-1167
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Provider Business Mailing Address
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Address Line | 924 N HOWE ST
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City | SOUTHPORT
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State | NC
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Zip | 28461-3038
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Country | US
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Telephone | 910-457-3800
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Fax | 910-457-3842
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0010-01344
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License Number State | NC
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