Provider Demographics
NPI:1114040029
Name:FARRAR, MIMSIE M (NP)
Entity Type:Individual
Prefix:MS
First Name:MIMSIE
Middle Name:M
Last Name:FARRAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 FOREST GLENN DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-1339
Mailing Address - Country:US
Mailing Address - Phone:209-521-7411
Mailing Address - Fax:209-521-2640
Practice Address - Street 1:3621 FOREST GLENN DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1339
Practice Address - Country:US
Practice Address - Phone:209-521-7411
Practice Address - Fax:209-521-2640
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP12314363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily