Provider Demographics
NPI:1538454129
Name:COUSINO, HEATHER NICOLE (PA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:COUSINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NW 13TH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2335
Mailing Address - Country:US
Mailing Address - Phone:561-338-3267
Mailing Address - Fax:
Practice Address - Street 1:3100 CORAL HILLS DR
Practice Address - Street 2:SUITE 307
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-4137
Practice Address - Country:US
Practice Address - Phone:954-796-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant