Provider Demographics
NPI:1013972512
Name:WIMMER, ROB (PA)
Entity Type:Individual
Prefix:
First Name:ROB
Middle Name:
Last Name:WIMMER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2085
Mailing Address - Country:US
Mailing Address - Phone:309-692-9898
Mailing Address - Fax:
Practice Address - Street 1:7309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2085
Practice Address - Country:US
Practice Address - Phone:309-692-9898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000410363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201632Medicare ID - Type Unspecified
ILR78361Medicare UPIN