Provider Demographics
NPI:1700937950
Name:WIMBERLY, MICHAEL R II (PT,MPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:WIMBERLY
Suffix:II
Gender:M
Credentials:PT,MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 LINDBERG AVE
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4884
Mailing Address - Country:US
Mailing Address - Phone:601-304-4161
Mailing Address - Fax:
Practice Address - Street 1:107 FRONT ST
Practice Address - Street 2:SUITE 230
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-2836
Practice Address - Country:US
Practice Address - Phone:318-336-2224
Practice Address - Fax:318-336-6068
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT04879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist