Provider Demographics
NPI:1477175446
Name:HARZAN, MIMI (MSPA, PA-C)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:HARZAN
Suffix:
Gender:F
Credentials:MSPA, PA-C
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:
Other - Last Name:CHARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSPA, PA-C
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-457-0469
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-13
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 390200000X
IL085008538363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program