Basic Information
| Provider Information | |||||||||
| NPI: | 1861664781 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WIMAHL FAMILY CLINIC, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WIMAHL FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 EXCHANGE ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033382993 | ||||||||
| FaxNumber: | 5033382996 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 EXCHANGE ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033382993 | ||||||||
| FaxNumber: | 5033382996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CORRINA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5033382993 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24702 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8377632 | 05 | WA | MEDICAID | 275225 | 05 | OR | MEDICAID |