Basic Information
| Provider Information | |||||||||
| NPI: | 1083797245 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIMBERLY | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF RADIATION ONCOLOGY | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124639 | ||||||||
| FaxNumber: | 3182128305 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 KINGS HWY | ||||||||
| Address2: | DEPARTMENT OF RADIATION ONCOLOGY | ||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711033950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182124639 | ||||||||
| FaxNumber: | 3182128305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 01/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA200094RX | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1706566 | 05 | LA | MEDICAID |