Basic Information
| Provider Information | |||||||||
| NPI: | 1063601607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEBERT | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2331 FRANKLIN RD SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Practice Location | |||||||||
| Address1: | 2331 FRANKLIN RD SW | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5407251226 | ||||||||
| FaxNumber: | 5408575306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2007 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110002647 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 0110002647 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1063601607 | 01 | VA | ANTHEM MEDIGAP | OTHER | 1063601607 | 01 | VA | UMWA | OTHER | P00834686 | 01 | VA | RAILROAD MEDICARE | OTHER | 1063601607 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | 1063601607 | 01 | VA | HUMANA MEDICARE | OTHER | 1063601607 | 01 | VA | AETNA | OTHER | 1063601607 | 01 | VA | CCC VIRGINIA PREMIER | OTHER | 1063601607 | 01 | VA | SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY | OTHER | 1063601607 | 01 | VA | INTOTAL | OTHER | 1063601607 | 01 | VA | MEDICAID QMB | OTHER | 1063601607 | 01 | VA | BLACK LUNG | OTHER | 540506332115 | 01 | VA | TRICARE/CHAMPUS | OTHER |