Provider Demographics
NPI:1508124587
Name:ERIC A NIMMO MD APC
Entity Type:Organization
Organization Name:ERIC A NIMMO MD APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:A
Authorized Official - Last Name:NIMMO
Authorized Official - Suffix:
Authorized Official - Credentials:MD APC
Authorized Official - Phone:907-357-3850
Mailing Address - Street 1:851 E WESTPOINT DR
Mailing Address - Street 2:STE 302
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7191
Mailing Address - Country:US
Mailing Address - Phone:907-357-3850
Mailing Address - Fax:907-357-3851
Practice Address - Street 1:851 E WESTPOINT DR
Practice Address - Street 2:STE 302
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7191
Practice Address - Country:US
Practice Address - Phone:907-357-3850
Practice Address - Fax:907-357-3851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK408723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1446Medicaid
AKB55382OtherUPIN
AK151080Medicare PIN