Provider Demographics
NPI:1518076520
Name:WIMBERLEY PEDIATRICS & ADOLESCENT MEDICINE, P.A.
Entity Type:Organization
Organization Name:WIMBERLEY PEDIATRICS & ADOLESCENT MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:HOPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-847-7700
Mailing Address - Street 1:180 JOE WIMBERLEY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WIMBERLEY
Mailing Address - State:TX
Mailing Address - Zip Code:78676-5997
Mailing Address - Country:US
Mailing Address - Phone:512-847-7700
Mailing Address - Fax:512-847-7701
Practice Address - Street 1:180 JOE WIMBERLEY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-5997
Practice Address - Country:US
Practice Address - Phone:512-847-7700
Practice Address - Fax:512-847-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL1706OtherSTATE LICENSE
TX1932104353OtherNPI
TXL1706OtherSTATE LICENSE
TX00471RMedicare ID - Type Unspecified