Basic Information
| Provider Information | |||||||||
| NPI: | 1124157441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIMBECKER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 930223 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 311930223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4703250100 | ||||||||
| FaxNumber: | 4703250193 | ||||||||
| Practice Location | |||||||||
| Address1: | 631 PROFESSIONAL DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300463367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783123500 | ||||||||
| FaxNumber: | 6783123529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2007 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 004977 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.