Basic Information
| Provider Information | |||||||||
| NPI: | 1992015747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEVCHIK O'BRIEN | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEVCHIK | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178224903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702716144 | ||||||||
| FaxNumber: | 5702716578 | ||||||||
| Practice Location | |||||||||
| Address1: | 224 N LOGAN BLVD | ||||||||
| Address2: | |||||||||
| City: | BURNHAM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170091850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172420196 | ||||||||
| FaxNumber: | 7172420701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2010 | ||||||||
| LastUpdateDate: | 05/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA054616 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50093217 | 01 | PA | CAPITAL BLUE CROSS | OTHER |