Individual
HEIDI LYNN TATUM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
87 SPRINGVIEW LN, SUMMERVILLE, SC 29485-9077
(843) 876-7979
Mailing address
PO BOX 602108, CHARLOTTE, NC 28260-2108
(843) 792-6200
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1101
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0526PA
—
SC
01
—
GP1551
MEDICAID GROUP
SC
01
—
P01173877
RR-MEDICARE
SC
Enumeration date
05/24/2006
Last updated
09/18/2018
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