Provider Demographics
NPI:1275883225
Name:ZIMMER, KRISTEN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:
Last Name:ZIMMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13636 DIX TOLEDO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2432
Mailing Address - Country:US
Mailing Address - Phone:734-283-2262
Mailing Address - Fax:734-283-8121
Practice Address - Street 1:13636 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2432
Practice Address - Country:US
Practice Address - Phone:734-283-2262
Practice Address - Fax:734-283-8121
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant