Provider Demographics
NPI:1336147768
Name:ZIMMERMAN, DONIELLE M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DONIELLE
Middle Name:M
Last Name:ZIMMERMAN
Suffix:
Gender:F
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 1:1200 N ELM ST
Mailing Address - Street 2:SUITE 411
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-3200
Mailing Address - Fax:336-832-3201
Practice Address - Street 1:301 E WENDOVER AVE
Practice Address - Street 2:SUITE 411
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1230
Practice Address - Country:US
Practice Address - Phone:336-832-3200
Practice Address - Fax:336-832-3201
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101135363A00000X
NC102812363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290763100Medicaid
FLE3461OtherBCBS
FLE3461UMedicare PIN
FLE3461RMedicare PIN
FLE3461VMedicare PIN
FLE3461SMedicare PIN
FLE3461OtherBCBS
FLS95796Medicare UPIN
FLE3461WMedicare PIN