Provider Demographics
NPI:1124473616
Name:MIMS, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N ESPLANADE ST
Mailing Address - Street 2:STE 102
Mailing Address - City:CUERO
Mailing Address - State:TX
Mailing Address - Zip Code:77954-4727
Mailing Address - Country:US
Mailing Address - Phone:361-275-2381
Mailing Address - Fax:
Practice Address - Street 1:2500 N ESPLANADE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CUERO
Practice Address - State:TX
Practice Address - Zip Code:77954-4723
Practice Address - Country:US
Practice Address - Phone:361-275-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-03
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX365219001Medicaid