Provider Demographics
NPI:1730625443
Name:HEO, JAE (PA-C)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:HEO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N PARK AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-4147
Mailing Address - Country:US
Mailing Address - Phone:407-889-1953
Mailing Address - Fax:407-303-0845
Practice Address - Street 1:201 N PARK AVE STE 105
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703
Practice Address - Country:US
Practice Address - Phone:407-889-1953
Practice Address - Fax:407-303-0845
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT 9110124363A00000X
FLPA9110124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant