Provider Demographics
NPI:1063492098
Name:WIMBERLY, ANGELIQUE ALEGRIA (PA)
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:ALEGRIA
Last Name:WIMBERLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELIQUE
Other - Middle Name:N
Other - Last Name:ALEGRIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:225-767-3900
Mailing Address - Fax:225-214-9109
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 1000
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-767-3900
Practice Address - Fax:225-214-9109
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA30227363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1581739Medicaid
LA232767OtherWELLCARE
LAQ03030Medicare UPIN
LA5C921P523Medicare ID - Type Unspecified