Provider Demographics
NPI:1326695792
Name:WALBERG, HEIDI MICHELLE
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:MICHELLE
Last Name:WALBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 AVON ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-2422
Mailing Address - Country:US
Mailing Address - Phone:408-931-2644
Mailing Address - Fax:
Practice Address - Street 1:1 LONG WHARF DR FL 6
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5991
Practice Address - Country:US
Practice Address - Phone:203-688-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT4630363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4630OtherSTATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH