1033551114 NPI number — KARISSA G ZIMMER PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033551114 NPI number — KARISSA G ZIMMER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ZIMMER
Provider First Name:
KARISSA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
KARISSA
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033551114
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2315 W. 57TH STREET
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-271-5441
Provider Business Mailing Address Fax Number:
605-271-5277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2315 W. 57TH STREET
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-271-5441
Provider Business Practice Location Address Fax Number:
605-271-5277
Provider Enumeration Date:
07/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0876 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1033551114 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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