Provider Demographics
NPI:1871731463
Name:WIMBERLEY, LISA L (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:WIMBERLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CUT OFF RD STE 14
Mailing Address - Street 2:
Mailing Address - City:PORT ARANSAS
Mailing Address - State:TX
Mailing Address - Zip Code:78373-4246
Mailing Address - Country:US
Mailing Address - Phone:361-749-1930
Mailing Address - Fax:
Practice Address - Street 1:600 CUT OFF RD STE 14
Practice Address - Street 2:
Practice Address - City:PORT ARANSAS
Practice Address - State:TX
Practice Address - Zip Code:78373-4246
Practice Address - Country:US
Practice Address - Phone:361-749-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX213446201Medicaid
TX213446202Medicaid
TX213446203Medicaid
TX213446203Medicaid
TXTXB104359Medicare PIN
TX213446201Medicaid