Basic Information
| Provider Information | |||||||||
| NPI: | 1700816568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZIMMER | ||||||||
| FirstName: | PAULA | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ZIMMER | ||||||||
| OtherFirstName: | PAULA | ||||||||
| OtherMiddleName: | S. | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22 CRAWFORD DR | ||||||||
| Address2: | |||||||||
| City: | BALLSTON LAKE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120192740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183841507 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 PARK ST | ||||||||
| Address2: | HOSPITALIST PROGRAM | ||||||||
| City: | GLENS FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128014413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189265918 | ||||||||
| FaxNumber: | 5189265917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 04/07/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | F4300063 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 02968032 | 05 | NY | MEDICAID |