Basic Information
| Provider Information | |||||||||
| NPI: | 1144512070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 SETON CENTER PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787594107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124391000 | ||||||||
| FaxNumber: | 5124391081 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 W 45TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787513014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124515800 | ||||||||
| FaxNumber: | 5124591399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 09/18/2015 | ||||||||
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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 | 364SA2200X | 746718 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 297997302 | 05 | TX | MEDICAID |