MEDICARE: HEATHER H ELLEDGE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	PA23119	CA
2	363A00000X	Physician Assistant	PA23119	CA

General Provider Information

NPI Number	:	1689006819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER H ELLEDGE PA-C

Provider Business Mailing Address
First Line	:	1154 E GRAND AVE
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2583
Country	:	US
Telephone Number	:	248-225-4408
Fax Number	:

Provider Business Practice Location Address
First Line	:	1154 E GRAND AVE
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-2583
Country	:	US
Telephone Number	:	805-395-3277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	06/20/2022

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Directions to “ HEATHER H ELLEDGE PA-C” Practice Location

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