Provider Demographics
NPI:1235839135
Name:WIMBERLY, DUEWARD SHANE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DUEWARD
Middle Name:SHANE
Last Name:WIMBERLY
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8535 TOM SLICK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3367
Mailing Address - Country:US
Mailing Address - Phone:210-582-6440
Mailing Address - Fax:
Practice Address - Street 1:8535 TOM SLICK
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3367
Practice Address - Country:US
Practice Address - Phone:210-582-6440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1111892363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health