Provider Demographics
NPI:1093093478
Name:DIMEIS, HEIDI LEIGH (NP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LEIGH
Last Name:DIMEIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3084
Mailing Address - Country:US
Mailing Address - Phone:315-500-7546
Mailing Address - Fax:315-378-4210
Practice Address - Street 1:5823 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3084
Practice Address - Country:US
Practice Address - Phone:315-500-7546
Practice Address - Fax:315-378-4210
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY51104-1163WG0000X
NY336829363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03372061Medicaid