Provider Demographics
NPI:1083797245
Name:WIMBERLY, HEIDI E (PA-C)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:E
Last Name:WIMBERLY
Suffix:
Gender:F
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 1:2600 KINGS HWY
Mailing Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3950
Mailing Address - Country:US
Mailing Address - Phone:318-212-4639
Mailing Address - Fax:318-212-8305
Practice Address - Street 1:2600 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF RADIATION ONCOLOGY
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3950
Practice Address - Country:US
Practice Address - Phone:318-212-4639
Practice Address - Fax:318-212-8305
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200094RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1706566Medicaid
LA5F600P790Medicare PIN