Provider Demographics
NPI:1861480600
Name:HERBOLSHEIMER, JUDY E (PA-C)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:E
Last Name:HERBOLSHEIMER
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:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0779
Mailing Address - Country:US
Mailing Address - Phone:989-362-2540
Mailing Address - Fax:989-362-9925
Practice Address - Street 1:25 M 55 E
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9362
Practice Address - Country:US
Practice Address - Phone:989-362-8691
Practice Address - Fax:989-362-7290
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601004037207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3043530Medicaid
MI3043530Medicaid