Provider Demographics
NPI:1629105085
Name:ZIMM, RICHARD C (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:C
Last Name:ZIMM
Suffix:
Gender:M
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 1:2315 MYRTLE ST STE L10
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4611
Mailing Address - Country:US
Mailing Address - Phone:814-454-2401
Mailing Address - Fax:814-459-5992
Practice Address - Street 1:2315 MYRTLE ST STE L10
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4611
Practice Address - Country:US
Practice Address - Phone:814-454-2401
Practice Address - Fax:814-459-5992
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052248363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y8753OtherBCBS
TX8L0108Medicare PIN