Provider Demographics
NPI:1124157441
Name:HEIMBECKER, RICHARD THOMAS (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:THOMAS
Last Name:HEIMBECKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 930223
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-0223
Mailing Address - Country:US
Mailing Address - Phone:470-325-0100
Mailing Address - Fax:470-325-0193
Practice Address - Street 1:631 PROFESSIONAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3367
Practice Address - Country:US
Practice Address - Phone:678-312-3500
Practice Address - Fax:678-312-3529
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004977363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical