Provider Demographics
NPI:1477265155
Name:DIMO, ALEXIS MIA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:MIA
Last Name:DIMO
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 1:1630 S PARKER RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9368
Mailing Address - Country:US
Mailing Address - Phone:734-660-8433
Mailing Address - Fax:
Practice Address - Street 1:1216 W WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2637
Practice Address - Country:US
Practice Address - Phone:419-515-5349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.008598RX363A00000X
MI5601012276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant