MEDICARE: HEATHER SUZANNE BROCK PA

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	363AM0700X	Medical Physician Assistant	003270	GA

General Provider Information

NPI Number	:	1891744827
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER SUZANNE BROCK PA

Provider Business Mailing Address
First Line	:	100 SAINT CLAIR PKWY
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-1007
Country	:	US
Telephone Number	:	678-446-7351
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 SAINT CLAIR PKWY
Second Line	:
City	:	SAINT SIMONS ISLAND
State	:	GA
Zip	:	31522-1007
Country	:	US
Telephone Number	:	678-446-7351
Fax Number	:

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

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	05/19/2016

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Directions to “ HEATHER SUZANNE BROCK PA” Practice Location

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