Provider Demographics
NPI:1790057438
Name:WIMMER, KACEY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KACEY
Middle Name:
Last Name:WIMMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KACEY
Other - Middle Name:
Other - Last Name:BRODIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 GEARY ST SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97322
Practice Address - Country:US
Practice Address - Phone:541-812-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA156855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant