Provider Demographics
NPI:1689095390
Name:WIMER, JIMMY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:WIMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1893
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1893
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2011 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2511
Practice Address - Country:US
Practice Address - Phone:541-963-4139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-23
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROBMI9015202471S1302X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography