Basic Information
| Provider Information | |||||||||
| NPI: | 1902070253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAMPLE | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHEETS | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2895 TUSCANIA LN | ||||||||
| Address2: | |||||||||
| City: | LEAGUE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775732385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8065188296 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775550591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097721221 | ||||||||
| FaxNumber: | 4097721224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | N7581 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 30087 | 01 | AL | ALABAMA LICENSE/DEA NUMBER | OTHER | N7581 | 01 | TX | TEXAS LICENSE NUMBER | OTHER |