Provider Demographics
NPI:1952804650
Name:KOOK-WILLIS, HEIDI JOONHEE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:JOONHEE
Last Name:KOOK-WILLIS
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78702-3412
Mailing Address - Country:US
Mailing Address - Phone:512-657-7294
Mailing Address - Fax:
Practice Address - Street 1:12731 RESEARCH BLVD STE 301C
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4383
Practice Address - Country:US
Practice Address - Phone:512-257-0497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136938363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty